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Response to intervention: the functional assessment of children returning to school with traumatic brain injury.

Traumatic brain injury to children ages 0-14 results in an estimated 435,000 visits to emergency medical departments each year (National Center for Injury Prevention and Control, 2009). Of these visits, 37,000 TBI children are hospitalized, with a reported 2,685 deaths. The number of unreported incidents of TBI is unknown. Survivors of TBI face a variable course of recovery that depends upon the type, location and severity of injury.

Traumatic brain injury is defined as a form of acquired brain injury that occurs when a sudden trauma causes damage to the brain and results from the head suddenly hitting an object or when an object pierces the skull and enters the brain (National Institute of Neurological Disorders and Stroke, 2009). Symptoms of TBI can be classified as mild, moderate or severe and can appear across multiple domains of functioning, including medical, sensory-motor, cognitive and social-personality (Brain Injury Association of Massachusetts, 2009). Medical symptoms include seizures, headaches, dizziness, weakness and fatigue. Sensory-motor symptoms include problems with coordination, balance, speech, sensation, hearing, and vision. Cognitive symptoms include impaired reasoning and memory, difficulty finding words, lack of safety awareness, distractibility and difficulty adjusting to change. Social-personality symptoms include agitation, anxiety, aggression, depression, emotional instability, substance abuse, and poor judgment and insight.

An ideal course of recovery includes a reduction in the number and severity of symptoms, and full recovery is not always possible. The course of recovery often involves short- and long-term gains during which time the symptoms improve and abate over a trend line of recovery. Successful case management often requires frequent and periodic observations of functional behavior, with modifications made to the medical and educational intervention to address the presentation of symptoms. The case management of children with TBI involves many interacting factors, including cognitive, behavioral, educational, social and family issues (Ylvisaker et al., 2005). Ultimately, the success of long term recovery includes the coordination of medical, educational and parental involvement.

Participation in programs to facilitate transition to the community and the school is an essential component of rehabilitation discharge. Todis and Glang (2008) followed 33 students with TBI. Students receiving transition services linking them to appropriate support agencies were more likely to complete their educational programming than students without such services. TBI victims who participated in community re-entry programs that taught compensatory strategies for cognitive deficits and that provided counseling and education for personal and family adjustment were more likely to demonstrate improvement on measures on overall disability (High, Roebuck-Spencer, Sander, Struchen & Sherer, 2006). Victims of TBI victims who started their transition services soon after discharge were more likely to demonstrate functional independence at follow-up than TBI who delay their participation. Such evidence favors a close collaboration between rehabilitation and educational agencies in order to provide transition services in a timely manner.

Despite the importance of transition services for students re-entering the school after a TBI, many students do not receive formal services. A survey of 56 youths with TBI indicated that 21 percent received formal hospital-to-school transition services while 41 percent received some informal support (Glang, Todis, Thomas, Hood, Bedell & Cockrell, 2008). The link between hospital and school is considered a critical factor in addressing the educational needs of the returning student. These results suggest that injury severity and a formal hospital-to-school transition service are significant factors in assisting with recovery as students return to school.

Children with TBI re-enter school with a variety of symptoms and degrees of severity. The manifestation of symptoms depend, in part, upon the type of injury (i.e., penetrating or non-penetrating), site and severity of injury, and the pre-morbid level of brain maturation prior to the injury itself (Spreen, Risser & Edgell, 1995). Depending upon these factors, children with TBI may present with combinations of medical, sensory-motor, cognitive and behavioral issues, including headaches, emotional lability, disinhibition, aggression, confrontational behavior, insensitivity and egocentricity. Disruptions of the sleep schedule are frequently reported, along with symptoms of irritability, fatigue, anxiety, depressed affect, apathy, and avoidance behaviors.

Given the injury severity of TBI patients, a functional assessment of behavior is often made to predict post-discharge adjustment. Gurka et al. (1999) found that functional assessment measures are useful in predicting productivity and community re-entry of TBI patients at 6 and 24 months post-discharge. To this end, a functional assessment of behavior can assist in identifying the degree of support needed by the post-discharge patient for successful entry into community and educational activities (Granger, Divan & Fiedler, 1995). In addition, results from psychological and neuropsychological assessments are commonly made available to assist with the transition to school.

The 2004 legislative re-authorization of IDEA (Individual's with Disabilities Education Act) requires school districts to conduct functional assessments of children who exhibit challenging behaviors in the school setting. Children with TBI often demonstrate a variety of these challenging behaviors. As such, children with TBI often avoid or withdraw from tasks perceived as difficult and of long duration. In addition, these children often avoid or withdraw from activities of social interaction when such activities are looked upon as a threat to their social competency. Under these circumstances, IDEA requests the development of a positive behavioral intervention plan to complement the functional assessment of behavior addressing these challenging behaviors.

Children with TBI often demonstrate a developmental trajectory that includes three stages of recovery (Corbett & Ross-Thomson, 1996). Children in Stage 1 often exhibit impaired efficiency of information processing along with displays of agitation, confusion, and impulsivity. Children in Stage 2 often exhibit intolerance for over-stimulation and a denial of cognitive disability. Children in Stage 3 show an increased understanding of the cognitive and social deficits associated with their brain injury, and an increased understanding of the lasting nature of these deficits. Consequently, children in the third stage of recovery often become susceptible to anxiety, anger, and depression.

The rate of recovery varies for each student, and this recovery can take on a fluctuating course. Short-term gains are often seen within the first 6 months post-accident, with a slower rate of improvement thereafter. Stabilization of functioning often occurs at 24 months post-injury. Nevertheless, progress varies for each child, depending upon the type and severity of brain injury and the amount of support provided.

A functional assessment of behavior allows for a quick and comprehensive method of charting the behavior of TBI children across all stages of recovery. The functional assessment is a process of quantifying the frequency, duration, intensity and severity of behaviors and allows the observer to identify the meaning and purpose of the behavior. Setting events, as well as antecedent and consequent events, are described to provide the context within which these behaviors occur. In this manner, a functional assessment of behavior involves a process by which to understand why a behavior occurs.

Treatment protocols often need readjustment due to the rapid changes of behavior seen during the early stages of recovery. Frequent and periodic observations of behavior are needed to assess student response to the interventions provided. In this manner, a response-to-intervention (RTI) strategy provides an ideal method by which to assess the effects of treatment and to make the quick and timely adjustments needed to fit intervention to the presenting symptoms.

Response-to-Intervention (RTI) is a legal term defined in the Individuals with Disability Education Act (IDEA 2004), which provides requirements for instructional services delivered to children with an identified Specific Learning Disability (SLD). Title 20 of the United States Code Section 1401(30) defines SLD as a disorder in one or more of the basic psychological processes involved in understanding or in using language, spoken or written, which disorder may manifest itself in the imperfect ability to listen, think, speak, read, write, spell, or do mathematical calculation. An SLD label can apply to children with other diagnostic labels, including perceptual disabilities, dyslexia, developmental aphasia, minimal brain dysfunction, and brain injury (i.e., brain injuries that are congenital or degenerative or brain injuries induced by birth trauma). However, the "brain injury" as defined in 20UAC 1401(30) is not the same as traumatic brain injury, which is defined as "an acquired injury to the brain caused by an external physical force" (Hozella, P, 2009, p. 16). Children with TBI often present with learning difficulties relevant to one or more of the defining conditions identified by IDEA 2004 as contributing to a specific learning disability (i.e., the imperfect ability to listen, think, speak, read, write, spell, or do mathematical calculations.) In addition, an RTI model has been successfully applied to students without a SLD, yet with a need for social behavioral support (Fairbanks, Sugai, Guardino & Lathrop, 2007). Although IDEA 2004 does not require RTI for children with TBI, the child with TBI can benefit from the intervention protocol used within the RTI framework to address academic and behavioral concerns.

The RTI model calls for a sequential tiered level of instruction, where the instruction is scientifically and empirically-based and the student's responses are measured. Tier 1 includes the observation and measurement of the student's responses to empirically-based traditional classroom instruction. If a student does not respond adequately, a Child Study Team meets to discuss instructional modifications and classroom accommodations. If Tier 1 intervention is unsuccessful, the student is referred to Tier 2; which involves a problem solving model to adapt the instructional protocol, including (1) problem identification, (2) problem analysis, (3) intervention development and implementation, and (4) intervention evaluation and modification. If Tier 2 intervention is unsuccessful, the child is referred to Tier 3, which involves special education including individualized instruction with a higher level of intensity.

Although the RTI model calls for a tiered sequence of three levels of instruction, students returning to school with TBI most likely return with Tier 2 or Tier 3 instructional needs. Glang et al. (2008) note that approximately 21 percent of students returning to school with TBI receive services typically provided in Tier 3; whereas, 40 percent of returning students receive services typically provided in Tier 2. Adapting the tiered approach of RTI will benefit most children returning to school with TBI symptoms.

Response-to-intervention is a recent all-school educational initiative designed to assist students in need of supportive instructional services. The response-to-intervention model is an IDEA 2004 initiative to replace the discrepancy model of identifying children with a Specific Learning Disability, and the response-to-intervention logic has been applied to children with other academic and behavioral difficulties. Indeed, the principles and concepts of a response-to-intervention paradigm have been discussed in the psychological literature for many years, and this literature offers much evidence of effectiveness and efficacy. In particular, the observation and measurement of children's responses to intervention provide abundant information to refine intervention strategy, and the functional assessment of behavior allows for this measurement at frequent and periodic intervals. Given the variety of academic and behavioral difficulties demonstrated by children with TBI, and the rapid yet fluctuating course of recovery, the functional assessment of behavior within a response-to-intervention modality allows for a flexible delivery of services to address the changing needs of children recovering from traumatic brain injury.

References

Brain Injury Association of Massachusetts. (2009). Brain injury. Retrieved June 24, 2009, from http://www.biama.org.

Corbett, S. L., & Ross-Thomson, B. (1996). Educating students with traumatic brain injuries: A resource and planning guide. Madison, WI: Wisconsin Department of Public Instruction.

Fairbanks, S., Sugai, G., Guardino, D., & Lathrop, M. (2007). Response to intervention: Examining classroom behavior support in second grade. Exceptional Children, 73(3), 288-311.

Glang, A., Todis, B., Thomas, C.W., Hood, D., Bedell, G., & Cockrell, J. (2008). Returning to school following childhood TBI: Who gets services? NeuroRehabilitation, 23(6), 477-486.

Granger, C.V., Divan, N., & Fiedler, R.C. (1995). Functional assessment scales: A study of persons after traumatic brain injury. American Journal of Physical Medicine and Rehabilitation, 74(2), 107-113.

Gurka, J. A., Felmingham, K., Baguley, I. J., Schotte, D. E., Crooks, J.,& Marosszeky, J. E. (1999). Utility of the functional assessment measure after discharge from inpatient rehabilitation. Journal of Head Trauma Rehabilitation. 14(3), 247-256.

High, W., Roebuck-Spencer, T., Sander, A., Struchen, M., & Sherer, M. (2006). Early versus later admission to postacute rehabilitation: Impact on functional outcome after traumatic brain injury. Archives of Physical Medicine and Rehabilitation, 87(3), 334-342.

Hozella, P. (n.d.). Building the Legacy: IDEA 2004: Identification of Children with Specific Learning Disabilities. Washington, DC: U.S. Office of Education National Dissemination Center for Children with Disabilities. Retrieved July 24, 2009, from http://www.nichcy.org/Laws/IDEA/Documents/Training_Curriculum/ 11-discussionSlides 1-19.pdf.

National Institute of Neurological Disorders and Stroke. (n.d.) Traumatic brain injury: Hope through research. Retrieved June 17, 2009, from http://www.ninds.nih.gov/disorders/tbi/tbi.htm

National Center for Injury Prevention and Control. (2009). Washington, DC: Center for Disease Control. Retrieved June 18, 2009, from http://www.cdc.gov/ncipc/factsheets/tbi.htm

Spreen, O., Risser, A., & Edgell, D. (1995). Developmental Neuropsychology. New York: Oxford University Press.

Todis, B., & Glang, A. (2008). Redefining success: Results of a qualitative study of postsecondary transition outcomes for youth with traumatic brain injury. Journal of Head Trauma Rehabilitation, 23(4), 252-263.

Ylvisaker, M., Adelson, D., Braga, L.W., Burnett, S.M., Glang, A., Feeney, T., Moore, W., Rumney, P., & Todis, B. (2005). Rehabilitation and ongoing support after pediatric TBI: Twenty years of progress. Journal of Head Trauma Rehabilitation, 20(1), 95-109.

BRUCE F. DYKEMAN, PH.D.

College of Education

Roosevelt University
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Author:Dykeman, Bruce F.
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Date:Dec 22, 2009
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