Improving Identification of Students with TBI
DONNA: Hi. I’m Donna Owens, the program director at the family center here at OCALI [PH]. With me today is Sarah Tams [PH], school psychologist for Columbus City Schools, and their TBI project coordinator. Thank you Sarah for being here.
SARAH: Thank you.
DONNA: The purpose of this web cast is to give school districts some ideas about how to improve the identification of students with TBI. And, Sarah, why is the identification of students with TBI a problem?
SARAH: Well there are many children with traumatic brain injury that are misidentified as a child with another disability cate-… under a disa-… different disability category. Or they are not identified at all. Uh, we know this because of the st-statistics that say, according to the CDC, over one million children sustain a traumatic brain injury every year. And of those, 130,000 are impaired enough to warrant special education services. However, in 2007, only 23,800 students received special education services under the TBI category.
DONNA: I can see that it’s a problem. How does that, uh, compare with Ohio’s TBI numbers?
SARAH: According to the higher department of ed, only 1116 children were served under the TBI category. More recent data from 2010-11, show that those numbers have only increased by 32 students. That tells us that children with traumatic brain injury are significantly underidentified, or misidentified.
DONNA: And then, so we’re missing a significant number of students, but how are students, uh, then misidentified?
SARAH: Many of these students has, have been identified as children with a learning disability, emotional disturbance, other health impairment, or another category, um, or not identified at all. These students may be considered lazy, a discipline problem, uh, unmotivated, um have attendance problems, uh, but nobody maybe has investigated why. Uh, even a student that is identified in special education in ano-another category, like learning disability, educators really don’t have a good understanding then, of why the child is having the difficulties that they’re having if they truly didn’t understand that they were from a brain injury.
DONNA: Um, could you explain the definition of TBI?
SARAH: Yes. It’s a long one. Um, Ohio has an expanded definition of a-… of TBI. So I’m just going to read it, and I’ll point out the differences between the federal definition under IDEA, and how Ohio has expanded it.
SARAH: Ohio’s definition of traumatic brain injury says that it is an acquired brain injury, or an acquired injury to the brain, caused by external, physical force, which is part of the federal definition. Ohio has added this. And other medical conditions, including, but not limited to, stroke, anoxia, infectious disease, aneurism, brain tumors, and neurological insults, resulting from medical or surgical treatments. This is back to the federal definition now. The injury results in total or partial functional disability, or psychological impairment, or both, that adversely affects a child’s educational performance. The term applies to open or closed head injuries. This is where again Ohio has expanded it. As well as to other medical conditions that result in acquired brain injuries. The rest of the inj-… uh, the definition is pretty consistent with the federal definition. And it says, the injuries result in impairments in one or more areas, such as cognition, language, memory, attention, reasoning, abstract thinking, judgment, problem solving, sensory, perceptual, and motor abilities, psychological behavior, physical functions, information processing, and speech. The term does not, however, apply to brain injuries that are congenital, degenerative, or to brain injuries induced by birth trauma.
DONNA: Mmhmm. So, the Ohio definition includes those children who acquire a TBI as a result of a medical condition, which could be cancer, or surgery, or infections that have caused damage to the brain. And the IDEA definition uses the word specifically of blunt force trauma, uh, due to things like a car accident, or a fall, or a shaken baby. So, what that means for Ohio is that Ohio should have a greater number of students identified with TBI than other states. Um, so we do know that these students are signific-significantly underidentified. Um, but they might be misidentified or identified under other categories. Why is it so important that we appropriately identify these students as TBI?
SARAH: As educators we know that if students are not appropriately identified, it may lead to educational needs not being met. One of the reasons we are not identifying these children is a lack of education and awareness of traumatic brain injury in the schools.
DONNA: Mmhmm. Um, well it’s clear it’s a problem. But, as a nation we are all learning more about TBI now, uh, thanks to a lot of national groups, uh and even the NFL. But, how is it that we make educators more aware?
SARAH: First of all I think we need to include our, the teachers. The staff, the students, the coaches, athletic coaches. Parents, global school community. They need to be better informed about traumatic brain injury and its prevalence. There needs to be a general awareness campaign, if you will. Uh, this can be done through inservices with teachers, and, and school staffs. Parent meetings, uh, posters, pamphlets, videos, such as we’re doing today. Um, just a general reaching out and trying to educate and spread the word to as many people as we can that would be involved with those children in our schools.
DONNA: Mmhmm. So we’ve talked about the importance of appropriate identification. Um, can you be more specific about the difference between TBI and then other disability categories. Uh, I mean, in-in the conditions that you mentioned, in the ways it might be impacted, aren’t some of their needs the same?
SARAH: They definitely are, um and that can be very con-… confusing to educators. Um, there, some of these children, of course have learning problems, processing delays, organizational, um, behavior problems. However, it’s important to make sure the educators understand why they’re-they’re having these difficulties. Um, all these-all these problems that we just identified can be very unpredictable. They’re not necessarily explained by other disability categories. Um, these problems may not be life long, these are not problems that these children have always had, necessarily. Um, and, they can recover over time. So, sometimes their injuries, um, right after their injury they have very severe needs and impairment, but as they recover, some of those needs improve. So, they-they look very different. Where, that’s not something you see necessarily in other children with other disability categories.
SARAH: Um, we also see on-on the flip side, children who have, were injured at a very young age, maybe before school, age three or four, and look like they heal medically very well, but then we start to see the delayed consequences of the brain injury when they hit maybe third or fourth grade, um, because we’re asking more of them, or demanding more of them at school and higher level thinking, and, and more just being thrown at them and expected of them, and we start to see those problems that were maybe related to the brain injury become more of an issue.
DONNA: Mmhmm, mmhmm. Well, what are some of the barriers, then to the proper identification of students with TBI?
SARAH: Incorrect identification in the schools can lead to inappropriate treatment, uh, support or no support at all. So some of the barriers maybe, that parents did not inform the schools of the injury, especially if it was an injury that occurred a long time ago and they feel their child had recovered, and they don’t think to bring it up. Um, they may not uh, we may not have a lot of medical information or medical documentation about the injury itself. Um, we may not truly understand the problems that they are experiencing, or, again, think that those problems are linked to that brain injury. Um, may not know how to support them. Um, one of the big barriers, I think for schools in general is just acquiring the medical documentation of the injury, again so that we can understand it better. Um, we do however need that medical documentation to con-… look at the dr-… the brain injury, and to look at eligibility for special education. For example, um, well we need that information to better understand it, but it also, if we know specifically what part of the brain was injured, so if it was the occipital lobe, we know the children, the child may have some difficulty with vision, and how we can better meet their needs then in the classroom, through accommodations or other supports. So those are the things you know, getting the medical documentation, one just to know that it happened, but then to of course understand what part of the brain, what was the follow up care what was the treatment the child had, kind of understand the entire, uh, picture, the whole story of the child after the injury.
DONNA: Well, you mentioned earlier about uh, some of the problems that can be caused by wrong identification. Um, can you expand on that some?
SARAH: Absolutely. Um, children as we mentioned with a traumatic brain injury can have behavioral problems, or show emotional problems after a brain injury. But those problems may not have been there before. And there’s not the result of necessarily result of a mental health diagnosis, or a mental health reason. Um, we may also see that these children have a lot of the previously learned skills in tact. They did not lose the knowledge that they had prior to the injury, necessarily. Um, but they may have a lot of problems acquiring new information. So, um, their needs may look… Or they could be even more specific in problems with um, their reading and writing skills may be very much impaired, but their math skills are still very strong. And so we may look at, they may look very impaired in one way, but not in another, because that part of the brain may not have been affected.
DONNA: Mmhmm. So, what are some of the important components then, for a school team to consider, when considering identification of TBI?
SARAH: School districts need to have, um, some screening tools in place to try to identify these children find them, and then of course, move forward. So uh, some of the things could be a health questionnaire, that is maybe sent out by the school nurses, um, it could be sent out to kindergarteners, new enrollees, all children. There’s a medical card, sometimes, schools always, like, obtain medical information. They could embed some questions in the medical card. Has the child ever had a brain injury, ever suffered a loss of consciousness, been hospitalized for type of head injury or um, you know brain tumors, or some questions that are probing like that. We could maybe even have, um, other ways to reach out could be questionnaires that are sent home to families, online surveys that parents might fill out. And then of course parent and teacher interviews. Uh, a lot of par-… uh, teachers call in parents before school’s even started, and ha-… just to get to know them, and they could ask those key questions at that time. Uh, there’s also the IAT process, that schools have, the intervention assistance teams that are more of a problem solving team, or support team in this building. Um, when we’re asking maybe about the academic concerns, we’re also asking about the medical history, and asking questions about that to learn a little bit more about what might’ve happened in this child’s past. Uh, some critical items, whatever tools the schools decide to use as a screening tool, some critical items to incl-include on that uh, questionnaire or information card, or whatever they’re trying to use is the age and time of the injury. We need to know maybe the severity of the injury. Did the child lose consciousness? Was there hospitalization? It could’ve been very brief, a few days, it could’ve been several weeks. So we need to know that. What was the treatment, or the follow up care after the injury? Did they have some outside therapies, uh, such as speech therapy, or occupational therapy? Um, what were some of the problems after the injury? So what was the child like before, what were some of the problems after? Uh, current con-… concerns, of course, what are the current issues, what is the child experiencing right now? And any other medical concerns that the child might have as a result of the injury, physical problems they may have. Or, sometimes they may have an inj-… uh, an issue that was prevalent before, such as ADHD. It’s definitely not better, after the head injury. So to know how that can be impacted as well.
DONNA: Mmhmm, mmhmm. So you’re-you’re talking about, um, educators listening for some embedded information or some, these embedded questions, but listening to the answers that parents may give, to these-to these questions…
DONNA: And seeing those as red flags…
DONNA: As an indication that we need to look further…
DONNA: Uh, about this.
DONNA: Um, and you also mentioned children being, um, injured, even prior to school.
DONNA: Maybe four or five years ago, maybe when they were-they were three years old.
DONNA: Can the school still identify them as a child with TBI, i-… when they’re in the third or fourth grade if it happened when they were three or four?
SARAH: Absolutely. Yes. It’s very important though, in those situations for the school to do a very thorough uh, parent interview, and cumulative file review, get the release of information signed to try to obtain those medical inf-… uh, records from that time of the injury, uh, and any follow up care. Because the child at that point may be healed and recovered in the best, medically, you know speaking, that they’re going to be, but doesn’t mean that they’re not still having problems. So if you can get it, the school can get the medical information, the information from the parents about the injury, to understand maybe what part of the brain was affected, what kind of care and intervention, if you will, medical intervention usually, that the child might’ve had back then, it can then, really kinda validate what’s going on now, and then that can give the educators a better idea of where to move forward from there. But just to get that documentation and the understanding.
SARAH: Absolutely those children are still eligible, can be eligible for support through TBI.
DONNA: Okay. And so then once they’ve-they’ve identified all, this is a clear possibility, we’ve gathered this information, we see that this is, this is a, a reasonable identification, uh and then what’s the next step?
SARAH: To determine as a school team, uh, what is the appropriate support plan that that child might need. And that can look very different, depending on the needs of that child. Um, it could be an intervention plan that the ch-… is created by that IAT, uh, once, like I said, the example you just gave about the older injury. That child might benefit from intervention, um, that the school can provide, and progress monitor it like we would, you know the response to intervention model. Um, we also could have an accommodation plan for children. This sometimes is more applicable to our students with concussion. Um, those, sometimes those injuries are more short term. Maybe three or four weeks, um, and while the child’s still experiencing symptoms of, related to the concussion, they need accommodations in a short term period, as they go through that recovery. But once they’re back to feeling um, basel-… back to their baseline, back to feeling how they were prior to the concussion, no symptoms, they may not need those supports anymore. So an accommodation plan could be helpful for them. We could go, take that a step further though, and maybe for children that may not meet the needs, or meet the definition of TBI under IDEA, we could meet their needs through a 504 plan. Um, and, and through accommodations and support through that, um, individual health plans are also a way of supporting children. These are often written by our school nurses. Uh, those are for maybe for children with a lot of the medical needs that would be supported by the school nurse or, or other medical re-… um, supports that are available in the school. And of course, the IEP, the individual education plan for children that do meet the definition established by the-the higher department of ed and IDEA.
DONNA: Mmhmm, mmhmm.
SARAH: So, the school team though, I think it’s important to inc-incorporate all the necessary people when you’re developing those plans, cause it’s really not a one person. It’s definitely a collaborative effort. It’s important to include the parent. They know the child best.
SARAH: So make sure they’re involved. Um, involve the medical doctor, the rehab team. If a child’s coming out of a rehab facility, um, or if they just go for follow up care, through a neuroso-neuros-… um, neurologist, or neuropsychologist, to follow up with those medical doctors to get their input, uh, involving the school psychologist. Involving the related services, like your OTs, your PTs, speech, uh, adaptive phys ed, the guidance counselor can be support in so many ways for the social reasons, and, and just, many different ways of, adjusting, helping that child adjust back to school. The school nurse is obviously a big part of it. Parent mentors. They’re very helpful in supporting our parents who are going through a very tough time. This is a very new experience for them too. And our parent mentors, um, can be very helpful and supportive to the parents um, helping them through it. Obviously general and special education teachers are involved. They are the ones implementing the plans on a day to day basis. Administrators, uh, supporting the plan and the overall process, and the support plan within the school. Our instructional assistants, uh, work very closely with some of these children, so they’re very important in being involved from the beginning, not just after the, at the end. And another one that sometimes we may not think about are the student’s close friends. This is a very tough time, these children often remember what they were like before the injury, and now they’re different. And so coming back to school and not having those supports in place, it, bringing their friends in and involving their friends, and being a support to them, and helping them help that child adjust to the, the school situation again. But no matter the plan, I think it’s very important for, a, for the school team to consider these specific areas when developing the plan. We need to remember, we’re thinking of the cognitive needs, the academic, and the communication needs of the child. The behavioral, emotional and social needs. The adaptive needs. The physical and motor needs if there are any. The overall medical health needs of the child.
SARAH: Environment and facilities, and this is one we may not think of, but sometimes these children come back um, may not remember how to get around the school. B-… it’s just their-their memory may be impaired for a while. Their planning skills. Um, they also may have physical needs like being within a walker, and may not be able to get upstairs. So I, it comes to mind that there was a principal in one of the buildings that said, well we’ll just move all his classrooms downstairs, so the child had all access to first level, and never had to worry about it. So, just you may need to modi-modify your building, or your environment somewhat to help that child’s transition be a little bit easier. And then finally of course thinking about transportation. If the child was a walker, he may, walking to school every day, he may not be able to do that now…
SARAH: So we may have to provide transportation for that child. So I think it’s important uh, in any way, whatever the plan is, that we respond to these children immediately, we don’t wait, and, we, um, we move to forward on implementing whatever the supports are that would meet that child’s needs um, immediately rather than later. We don’t need to wait for that child to fail, to have trouble getting back and adjusting to the school. We need to know those needs coming in, hopefully even before the child steps back into the school after the brain injury, and have those supports in place. It’s kind of like looking at the RTI triangle, how we look at it when we’re looking at children with learning disabilities that we kind of look at tier one, and then we move to a more intensive intervention, and then to the most intensive. Think of it flipping that triangle over, and giving them the most intensive intervention in the beginning, and pulling away as the child no longer needs those interventions, as they recover and get better, they may not need that support. So, it, I think it, to best serve that child’s needs, is to give them everything they can in the beginning, and pull away as they no longer need it.
DONNA: Mmhmm, mmhmm. Well, one of the things that you’ve certainly taught us here is that we have to take a comprehensive look at children with TBI.
DONNA: I mean, uh, across the board what their needs are, across the board in terms of what supports that we have to offer and when we have to offer those supports too.
DONNA: Um, I guess I also think about, what about those children that have been hospitalized say, for an extended period of time, six, seven months, maybe even out of school for a year.
DONNA: Um, what is it that schools can do for them, or need to think about doing for them?
SARAH: The first thing I would do is definitely uh, contact, if they were hospitalized like you said, let’s start there. Contacting that school, that hospital team, and working with them on the transition. Um, Columbus City Schools often works with our children coming out of the Nationwide Children’s Hospital, um, rehab facility. We will go to the hospital as our, with our school team and meet with their entire rehab team, and get their recommendations, and how we can incor-… find out how we can incorporate them into our school setting, and, they know the child best from the medical side of things. We need to take those recommendations, see how we can meet their needs, then with our educational supports that we have in place. And, most importantly think outside the box. Take what we’re hearing from the medical staff, take what we have, and then try to find a way to meet that child’s needs in, in between. But we can’t always go with the approach of, what’s always worked in the past, because this is a very different unique situation. So thinking outside of the box, being creative, and most importantly always keeping in mind, how can we meet this child’s needs immediately, and, and best support him with all the supports that they need, and like I said pull away as they don’t need those anymore.
DONNA: Mmhmm. Sarah thank you very much for your time, I do really appreciate it. Um, and, uh, thank you for offering us the tools that Columbus uses, you gave us a mo-… uh, an accommodations and modifications list, and also the uh, the questionnaire, that-that you use for kindergarteners and all new enrollees, is that right?
SARAH: Mmhmm. Yes, the health questionnaire, and then there’s the survey.
DONNA: Mmhmm. And the survey that you use. And those tools are, will be available on the website here, and, uh, you’ll be able to download those if you need them. Thank you very much Sarah.
SARAH: Thank you.
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