Module II ______________________________________________________

1
Module II_______________________________________
_______________

• Understanding TBI

2
Module II Goal______________________________

• To present information about the brain and how
  injury to the brain affects the student and family

3
Module II Learning Outcomes ______________________
________________________________

• At the end of this module you will understand
• Incidence and prevalence of TBI
• Mechanisms of brain injury
• Wisconsins definition of TBI
• Basic brain structures and functions
• Effects of TBI on student and family

4
Brain Injury Why do we need to know about
it?______________________________________________
_______

• More students are surviving serious brain injury
  (BI) than ever before
• Much of a students recovery from BI occurs AFTER
  returning to school

5
Brain Injury Why do we need to know about
it?______________________________________________
________

• Students with BI often have difficulty with
  learning and behavior that stems directly from
  their brain injuries
• Educators have many skills we can use once we
  understand the needs of students with BI

6
Incidence and Prevalenceof BI___________________
____________________________________

• 1 in 500 students sustain an acquired BI each
  year in the U.S.
• 1 in 25 students will sustain an acquired BI
  before high school graduation
• Overall twice as many boys as girls

7
Brain Injury Three Students_____________________
__________________________________

• Mike
• Monty
• Serena

8
Primary Causes of BI by Age______________________
________________________________

• Infants
• Abuse neglect
• Toddlers
• Abuse falls
• Early Elementary
• Falls pedestrian-motor vehicle accidents

9
Primary Causes of BI by Age______________________
_________________________________

• Late elementary/Middle school
• Pedestrian-bicycle accidents
• Pedestrian-motor vehicle accidents
• Sports
• High school
• Motor vehicle accidents
• (Savage Wolcott, 1994)

10
Brain Injury Terms Definitions
_________________________________________________
______

• Acquired Brain Injury
• Congenital and Perinatal Brain Injury
• Traumatic Brain Injury
• Open Head (brain) Injury
• Closed Head (brain) Injury

11
Acquired Brain Injury___________________________
____________________________

• Brain injury incurred after a period of normal
  development
• Internal causes
• External causes

12
Congenital and PerinatalBrain Injury____________
__________________________________________

• No period of normal development
• Congenital a condition a child is born with
  (e.g., metabolic disorder, chromosomal
  abnormality)
• Perinatal a condition that develops around the
  time of birth (e.g., perinatal stroke)

13
Traumatic Brain Injury ___________________________
____________________________

• TBI in Wisconsin Schools
• Occurs after a period of normal development
• Not congenital, degenerative, or due to birth
  trauma
• Occurs as a result of external physical force to
  the brain (e.g., as a result of a bike or car
  accident or a gunshot wound)
• Meets WI PI 11 criteria for TBI

14
Types of Traumatic Brain Injury__________________
_____________________________________

• Open Head/Brain Injury Brain injury in which the
  skull, meninges, and brain are penetrated by an
  external object (e.g., gunshot)
• Closed Head/Brain Injury Brain injury in which
  the skull and meninges are NOT penetrated (e.g.,
  head hits the dashboard)

15
Open Head/Brain Injuries_________________________
______________________________

• Penetrating Injuries
• Projectiles such as bullets or nails
• Sledding accidents
• More likely to experience seizures than closed
  head injuries

16
Closed Head/Brain Injury_________________________
______________________________

• Anoxic Episodes
• Near-drowning
• Strangulation
• Smoke inhalation
• Focal Injuries
• non-penetrating blows

• Acceleration/ deceleration Injuries
• Falls
• Vehicular accidents
• Shaken baby syndrome
• Sports accidents

17
Closed Head/Brain Injuries_______________________
________________________________

• More common than open head/brain injuries
• Cause more diffuse damage to the brain than open
  head/brain injuries
• Coup/contracoup mechanism of injury

18
Mechanism of injury Coup/Contracoup_____________
_________________________________________
Reprinted with permission from the North Carolina
Department of Public Instruction
19
Primary Effects of Closed Head/Brain
Injury___________________________________________
___________

• Injury to brain tissue at the site of coup and
  contracoup
• Shearing and tearing of neurons throughout the
  brain

20
The Neuron_______________________________________
_______________

• Graphic courtesy of Marshfield Clinic

21
The Neuron_____________________________________

• Gray matter nerve cell bodies
• White matter nerve axons coated with a myelin
  sheath
• Myelinization facilitates rapid transmission of
  impulses along the axon
• Bundles of neurons make up nerves that run from
  the brain to the spinal cord

22
Secondary Effects of Closed Head/Brain
Injury___________________________________________
____________

• Bleeding (contributes to increased intracranial
  pressure)
• Swelling (contributes to increased intracranial
  pressure)
• Lack of oxygen to the brain (results in cell
  death)

23
Before and After BI______________________________
________________________

• Speed limit 25

• Speed limit 65

24
Types of Brain Injury____________________________
__________________________
25
Predictors of Outcome after BI___________________
___________________________________

• Duration of coma
• Post-traumatic amnesia (PTA)
• Age
• Location of injury
• Pre-injury functioning
• Support systems

26
Outcome Predictors Coma_________________________
_____________________________

• Coma is a state of unconsciousness in which the
  person cannot be aroused or does not respond,
  even to painful stimuli
• Coma is measured along a continuum of levels of
  responsiveness
• No or brief coma is generally a more positive
  predictor than longer coma

27
Coma Scales ______________________________________
________________

• Assess responsiveness to environmental stimuli
• Examples
• Glasgow Coma Scale
• Rancho Los Amigos Scale of Cognitive Levels

28
Outcome PredictorsPost-Traumatic Amnesia
(PTA)____________________________________________
__________

• Retrograde Failure to remember events leading up
  to injury
• Anterograde Failure to accumulate new memories
  after injury

29
Outcome Predictors Age__________________________
____________

• Young children are especially vulnerable to the
  effects of brain injury
• Previously developed skills may be preserved
  after brain injury, but new learning may be
  difficult
• Effects of brain injury may not be apparent until
  more advanced skills are expected to develop

30
Other Outcome Predictors ________________________
______________

• Location of injury
• Pre-injury functioning
• Support systems

31
Severity of BI Mild_____________________________
_________________________

• Brief or no loss of consciousness
• Signs of concussion
• Nausea and vomiting
• Headache
• Fatigue
• Dizziness
• Poor recent memory
• Post traumatic amnesia less than 1 hour
• GCS of 13-15

32
Severity of BI Moderate_________________________
______________________________

• Coma less than 24 hours
• Post-traumatic amnesia 1- 24 hours
• GCS of 9-12

33
Severity of BI Severe___________________________
____________________________

• Coma more than 24 hours
• Post-traumatic amnesia more than 1 day
• GCS 3-8

34
Student examples_________________________________
______________________

• Mike
• Monty
• Serena

35
How does a student with BI qualify for special
education services?______________________________
________________________

• To be identified as a student with TBI, the
  student must meet the Wisconsin definition of TBI
• Not all students with BI meet the Wisconsin
  criteria for TBI

36
Traumatic Brain InjuryWhat is it?
__________________________________________

• TBI became a special education handicapping
  condition in IDEA in 1990
• TBI was added to Wisconsins special education
  law (Chapter 115) and rules (PI 11) in 1995.
• TBI is one of 11 areas of impairment listed in
  Wisconsin Chapter 115

37
Wisconsin Definition of TBI______________________
_________________________________

• The Wisconsin TBI definition has four parts
• The entire definition from Wisconsin PI ll is
  printed on the next page of your manual

38
Wisconsin TBI Definition Part 1_________________
______________________________________

• Traumatic brain injury
• an acquired injury to the brain
• caused by an external physical force
• resulting in total or partial functional
  disability or psychosocial impairment, or both
• adversely affects a childs educational
  performance

39
TBI Definition (part 1 cont.)____________________
___________________________________

• open or closed head injuries
• impairments in one or more
• cognition speech and language memory
  attention reasoning abstract thinking
  communication judgment problem solving
  sensory, perceptual and motor abilities
  psychosocial behavior physical functions
  information processing and executive functions

40
TBI Definition (part 1 cont.)____________________
____________________________

• Executive functions are planning, prioritizing,
  sequencing, self-monitoring, self-correcting,
  inhibiting, initiating, controlling or altering
  behavior. (Savage Wolcott, 1995, p. 150).

41
TBI Definition (part 1 cont.)____________________
___________________________________

• The term does NOT apply to brain injuries that
  are congenital or degenerative, or brain injuries
  induced by birth trauma

42
TBI Definition Part 2___________________________
____________________________

• Acquired injuries to the brain caused by INTERNAL
  occurrences are NOT TBI
• Injuries due to INTERNAL causes MAY meet criteria
  for other areas of impairment

43
TBI Definition Part 3___________________________
____________________________

• Standardized and norm-referenced instruments may
  not be reliable or valid
• Alternative means of evaluation shall be
  considered

44
TBI Definition Part 4___________________________
____________________________

• Before a child may be identified with TBI
  available medical information from a licensed
  physician shall be considered.

45
Incidence of TBI in Wisconsin Schools___________
___________________________________________

• 431 students identified with TBI per PI 11
  criteria (as of December 1, 2005)

46
The Brain________________________________________
______________

• Weighs about three pounds and is the consistency
  of jello
• Contains billions of neurons
• Videotape (optional)

47
Components of the Brain__________________________
_____________________________

• 1. Brainstem
• 2. Cerebellum
• 3. Basal Ganglia
• 4. Diencephalon
• 5. Limbic System
• 6. Cerebral Cortex
• See Brain Surface map on next page

48
The Brainstem____________________________________
___________________

• At the base of the brain above the spinal cord
• Comprised of the medulla, pons, and midbrain
• Responsible for basic life functions
• Severe injury causes death

49
The Cerebellum___________________________________
___________________

• Primarily helps modulate motor responses
• Regulates direction, rate, force, and steadiness
• Injury disrupts coordination and muscle tone

50
Basal Ganglia____________________________________
__________________

• Nerve cell clusters involved with regulation of
  physical movement
• Injury results in involuntary movements, slowness
  or tremor

51
The Diencephalon_________________________________
_____________________

• Main organs thalamus and hypothalamus
• Hypothalamus controls hunger, thirst, sleep,
  body temperature, hormones important role in
  emotional regulation
• Thalamus relays information regarding sensation
  and movement

52
The Limbic System________________________________
______________________

• Main organs hippocampus and amygdala
• Hippocampus memory retrieval
• Amygdala emotional memories

53
The Cerebral Cortex______________________________
________________________

• Center of conscious brain activity
• Divided into two hemispheres connected by the
  corpus callosum
• The right side of the brain controls the left
  side of the body and vice versa
• Dominant hemisphere represents language (usually
  left hemisphere)

54
The Lobes of the Cerebral Cortex_________________
_____________________________________

• Each hemisphere of the brain is divided into four
  lobes
• Frontal
• Temporal
• Parietal
• Occipital

Reprinted with permission from the North Carolina
Department of Public Instruction
55
The Frontal Lobes________________________________
______________________

• Susceptible to injury
• Control executive functions
• Deficits may become apparent as student develops
• Motor cortex

56
The Parietal Lobes_______________________________
_______________________

• Receives, analyzes, and integrates sensory and
  motor stimuli
• Recognizes touch, location in space
• Role in recognizing faces, objects, and ability
  to assemble and draw
• Spatial neglect

57
Motor and Sensory Strips_________________________
_____________________________

• The motor and sensory strips are located on
  either side of the central sulcus
• The motor strip is responsible for movement
• The sensory strip is responsible for sensation

Reprinted with permission from the North
Carolina Department of Public Instruction
58
The Temporal Lobes_______________________________
_______________________

• Receives, analyzes, and integrates auditory
  information
• Center for language Expressive fronto-temporal
  area Receptive tempero-parietal area
• Forms memories

59
The Occipital Lobes______________________________
________________________

• Receives, analyzes. integrates visual
  information
• Visual disturbances such as restricted vision,
  impaired visual recognition, and scanning
• Optic nerve travels through the brain to the eyes

60
Effects of Brain Injury Infants and Toddlers
_________________________________________________
______

• The very young brain is like custard
• Limited head control results in shearing of
  brain
• Open fontanels mean less brain protection
• More frequent seizures than older children
• Motor and expressive language skills susceptible
• Interrupted synaptic connections have cascading
  effect
• Focal injuries may have better outcome

61
Effects of Brain Injury Elementary and Middle
School Students

• During this time the childs brain is
  supercharged or rapidly developing
• Connections between the two hemispheres of the
  brain and within each hemisphere become more
  efficient
• Brain injury during this period interrupts
  development of critical cognitive and
  communication skills

62
Effects of Brain Injury High School Students

• Myelinization of the frontal lobes and more
  efficient connections within the brain facilitate
  development of logical thinking and ability to
  solve complex problems
• Previously developed skills are more resistant to
  effects of brain injury
• Psychosocial effects of brain injury threaten
  adolescents sense of self

63
Three Students ___________________________________
____________________

• What types of difficulties in school do you
  expect these students to exhibit?
• Mike
• Monty
• Serena
• Refer to worksheet on p. 34d

64
How can you determine how TBI affects an
individual student?______________________________
__________

• Review the students medical record. What part(s)
  of the brain were injured?
• Review hospitalization records, discharge
  summary, therapist reports.
• Ask medical staff how the BI will affect student
  functioning.
• Ask family members, teachers, and peers what they
  are seeing.
• Observe/interview the student.

65
Can brain injuries be repaired?__________________
____________________________________

• Research tells us
• Once neurons are severed they cannot yet be
  repaired.
• The brain generates new brain cells, but we do
  not yet know how to direct these cells to become
  neurons.
• Over time the secondary effects of brain injury
  subside, new information pathways may develop,
  and functioning generally improves.

66
What happens to the student and family after the
injury?
67
Typical Medical Course for a Student with a
Moderate/Severe ABI______________________________
________________________

• Emergency room
• Regional trauma center if
• necessary
• Surgery if necessary
• Acute care setting (hospital)
• Rehabilitation unit or center
• School

68
The Impact of ABI on Families____________________
___________________________________

• Families are in extreme emotional distress after
  a childs injury
• Parents immediate concern is life and death
• Parents become experts about ABI

69
Child and Family Stages after ABI________________
_______________________________________

• Child
• Initial Injury
• Coma
• Rehabilitation
• Reintegration

• Family
• Shock, grief, crisis
• Hope, disruption of family life, fear
• Reestablishing family routines, emerging
  awareness of extent of injury, isolation
• Altering dreams, long-range planning

70
Within The First Year After ABI__________________
_____________________________________

• Emotional resources available to the family
  decrease
• Family members begin to see evidence of cognitive
  and behavioral aftereffects
• Family begins to understand that the child may
  have permanent impairments
• (Corbett Ross-Thomson, 1996)

71
End of Module II