Brain Injury in Children and Youth A Manual for Educators Revised 2018 ACKNOWLEDGMENTS In 2001, the Traumatic Brain injury (TBI) Manual was written as a joint effort between the Colorado Depart- ment of Education, the New Start Project within the Center for Community Participation at Colorado State University in Fort Collins, Colorado, and the Children’s Hospital Colorado. Since 2001, brain injury research and practice has changed significantly. In 2012, the Colorado Brain Injury Steering Committee, led by Karen McAvoy and Judy Dettmer, was instrumental in updating the TBI Manual and creating the stand alone spe- cial education eligibility category and criteria for TBI, which was formally adopted into the Colorado Rules for the Exceptional Children’s Educational Act (ECEA). The newest version of this manual was revised in 2018 by: Judy Dettmer, B.S.W., Director, MINDSOURCE Brain Injury Network, Colorado Department of Human Services Jeanne E. Dise-Lewis (†), Ph.D., Psychologist, Rehabilitative Medicine, Children’s Hospital Colorado, Died September 18, 2014 † Deceased. Patricia W. Colella, M.A., C.A.G.S., School Psychologist Nicole Crawford, Ph.D., Psychologist, Brain Injury Specialist, Colorado Department of Education Heather Hotchkiss, M.S.W., Principal Brain Injury Specialist, Exceptional Student Services Unit, Colorado Department of Education Karen McAvoy, Psy.D., Psychologist, Brain Injury Specialist, Colorado Department of Education Peter Thompson, Ph.D., School Psychologist, Douglas County School District Janet Tyler, Ph.D., Senior Brain Injury Specialist, Health and Wellness, Colorado Department of Education With additional assistance from: Tami Cassel, M.A., CCC-SLP, Speech-Language Pathology Consultant, Colorado Department of Education Donna Detmar-Hanna, M.S., OTR, Occupational Therapist, Poudre School District Jayne Dougherty, OTR/L, Occupational Therapy, Physical Therapy and Adapted Physical Education Specialist, Colorado Department of Education Edited by: Matthew Colella, blue13creative Thanks to all contributors over past years who have made this a valuable resource for parents and educators. i COLORADO DEPARTMENT OF EDUCATION TABLE OF CONTENTS Overview of the Manual......................................................1 Chapter 1: The Brain: Basic Neuroanatomy/Neurophysiology and Developmental Stages . .7 Chapter 2: Developmental Stages and the Effects of an Acquired Brain Injury . .10 Infancy Stage: Birth to 3 years . 11 Preschool Stage: Ages 3 to 6 years . .12 Elementary School Stage: Ages 6 to 12 years . 14 Early Adolescence: Ages 12 to 16 years . .16 Late Adolescence: Ages 16 to 19 years . .18 Chapter 3: Building Blocks of Brain Development . 20 Fundamental Processes . .23 Attention & Concentration . 24 Inhibition . 27 Processing Speed . 28 Memory . .30 Sensory and Motor . 32 Intermediate Processes . .35 New Learning . .36 Language (Social Pragmatics) . 38 Visual-Spatial . .41 Higher Order Processes . .42 Executive Functions Executive Function: Initiation . 43 Executive Function: Planning . 44 Executive Function: Organization Skills . 45 Executive Function: Mental Flexibility . .47 Executive Function: Reasoning, Problem-Solving, and Judgment . .48 Social/Emotional Competency . .50 Function of the Behavior . 53 Functional Behavior Assessment (FBA) . 54 Behavior Intervention Plan (BIP) . 57 Factors Specific to Brain Injury . .60 Unevenness . 60 Fatigue/Endurance . 61 Transition . .62 Secondary Transitions . .64 Chapter 4: Brain Injury Identification and Supports in Schools ......................66 School Re-Entry . 66 Implications for Schools . .66 Types of Brain Injury . 67 Special Education . 68 Appendices . .73 BRAIN INJURY MANUAL ii Appendix A: Identification Flow Chart . 74 Appendix B: Traumatic Brain Injury Eligibility . 75 Appendix C: Initial Health History . .78 Appendix D: Brain Check Survey . 80 Appendix E: Neurocognitive Evaluation Form . 85 Citations and Resources .....................................................96 iii COLORADO DEPARTMENT OF EDUCATION Overview of the Manual Introduction You might be wondering why you as an educator or school staff member should be interested in brain injury. Many people do not realize how common it is for children to sustain a brain injury. Traumatic Brain Injury (TBI) is a leading cause of death and disability among children ages 1 to 19 years in the United States (Faul, Xu, Wald, & Coronado, 2010). Each year, approximately 40 percent of TBIs in the United States occur in the pediatric population (ages 0 to 19 years) (Faul et al., 2010). The Centers for Disease Control (CDC) estimates that more than 60,000 children and adolescents are hospitalized annually in the United States after sustaining moderate to severe brain injuries from motor vehicle crashes, falls, sports and physical abuse with an additional 631,146 seen in hospital emergency rooms and released (Faul et al., 2010). In all, nearly 145,000 children aged 0 to 19 years are currently living with long-lasting, significant alterations in social, behavioral, physical and cognitive functioning following a TBI (Zaloshnja, Miller, Langlois, & Selassie, 2008). The Colorado Department of Public Health and Environment (CDPHE) reported the rate of Traumatic Brain Injury was twice as high for Colorado boys and young males ages 0 to 20 years (71.7 TBIs per 100,000 population) than the rate for Colorado girls and young females of the same age (36 per 100,000). The leading causes of non-fatal TBI among Colorado children and youth were motor vehicle-related events in traffic or on public roads and falls. Two additional causes more common among children and youth than adults were those involving other transportation (including motor vehicles not in use on public roads, off-road vehicles, trains, airplanes and water transport) and being struck by/against a person or object such as in recreational and sporting events. Although TBI is a high-incidence medical event, the U.S. Department of Education and most state departments of education consider TBI a “low-incidence” educational disability. A significant discrepancy between the incidence of TBI and the identification of children with TBI for special education services continues to exist. Although approximately 145,000 children live with persistent disability following TBI (Zaloshnja et al., 2008), the total number of students receiving special education services under the TBI category is only 27,000 (U.S. Department of Education, 2015-16). Given that 60,000 children are hospitalized each year for TBI it is likely that many of them are not receiving the services they need (Faul et al., 2010). Rates of special education identification are higher for some students with TBI, including those with severe TBI, problem behavior, poor academic performance, and socio-economic disadvantage (Donders, 1994; Ewing-Cobbs, Fletcher, Levin, Iovino, & Miner, 1998; Max et al., 1998; Miller & Donders, 2003; Taylor et al., 2003). This discrepancy exists across all states, including Colorado. Since 2014, in Colorado, over 500 students have been identified with a brain injury as their primary disability category for special education. Comparing this to data from the CDPHE which says approximately 2,000 youth ages 0 to 20 years are discharged from the hospital with TBI each year, there may be a significant number of students who are either receiving services under an inappropriate disability category or are not receiving special education services at all. While it is difficult to determine how many youth who sustain TBI will experience any long-term educational impact requiring special education support, the Pediatric Registry suggests approximately 19 percent of moderate-to-severe brain injury will result in on-going, life-long impairment. This data would suggest that we are grossly under-identifying students with brain injury that may benefit from special education services. Additionally, this data only reflects injuries that were of a significant enough medical nature to require hospitalization. Therefore, those with medically “mild” TBI (concussion) who were treated and released from the hospital or who perhaps never sought medical care are not included in these numbers. Schools and districts specifically wanting more information on concussion identification and management and state concussion legislation (Senate Bill 11-040) should refer to the Colorado Department of Education Health and Wellness Brain Injury web page. BRAIN INJURY MANUAL 1 School personnel MUST know how to look for subtle and longer-term effects on any and all students who sustain either a traumatic or non-traumatic brain injury. However, there are many reasons why staff may not realize a student in their classroom has sustained a brain injury: u If the injury occurred in infancy or before they reached a seemingly “mild” brain injury may impact school school age, parents may not realize there could be a performance and learning ability. connection with learning/behavioral problems and the u A parent may not want to tell the school about injuries injury. Parents are often told by health care providers that have occurred during domestic violence/child abuse that there will not be any long-term effects of the injury incidents or injuries that reflect poorly on their supervision and they don’t report the history when their child starts and care. school. u Parents may not know of their child’s participation u The information about the injury may not follow the in “problem” activities, such as “huffing” or playing child