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>> We are very happy to be here. As Brenda said, I'm Heather Hotchkiss. Our trip in from Colorado was not too terribly bad, so that's good. It was a long day yesterday, because we left at
oh-dark-thirty yesterday, but we were able to go to chocolate world! [Laughter] That was fabulous.
So you've kind of gotten my background; I'm not even going to fill in any more, other than what Brenda said. If you've got any questions for us, let us know. But we just wanted to start off thanking
you for what you do. We know it is a tough gig in education these days. And a lot is coming at you, just as it is in Colorado. So thank you for your time, and everything you do day in and day out. So
-- and will turn it over to Karen.
>> Great. Okay. Good morning. I will go ahead and start us off this morning, but Heather and I will pretty much go back and forth as the day goes on. We want to -- we want to present just some of the
things that we do in Colorado; some content, some ideas, but we also want to have time for case studies. We also want to make sure we are answering your questions, meeting your needs today. So before
we go any further, because we can kind of adjust as we go, we wanted to get a sense of who we have in the room today. Can you let me know if you are general ed teachers here? Special education
teachers here? Excellent, okay. Do we have school social workers? School psychologists? Okay, school nurses? Speech-language? Excellent, okay. OT's? PT? Excellent. Administrators? Wow, a lot of
administrators. Who else did I forget?
>> Parents? Excellent. Okay, and how many of you guys are on the BrainSTEPS teams? All right, so quite a bit of you. All right. So if we had to say between zero to ten -- zero, never heard anything
about brain injury before 10, like you are an expert on brain injury.
>> I'm just going to take your seat. [Laughter]
>> How many of you guys would sort of rate yourself maybe zero to two, kind of a new introduction to brain injury? Okay, two to four? Kind of learning some, getting more information? All right. Four
to six? Excellent. Yeah, you guys do such great training out here. When Brenda asked us to come, we're, like, "Why are we coming out here?" You guys should come and train us in Colorado. Six to
eight? All right. Eight to ten? Brenda? Come on up here!
All right. So we just wanted to get a sense of where people were feeling their expertise was, where we should adjust as the day goes on. We have some objectives that we put together that we want to
make sure that we hit today. And you can see, we'll talk about kind of the hierarchy of neurocognitive development. When Heather and I do this training in Colorado, we go back and forth between
really trying to train what is unique about traumatic brain injury, how does that differ from acquired brain injury, but then we're constantly then saying, but how would you apply this to all
neurologically-based disorders? So how would this, then -- how would you use any of this with your kiddos that you're working with that are on the spectrum, that potentially have FASD? How would you
use this with kids who have seizure disorders? And so many of the assessments and the interventions will go back and forth with kids that you're working with, and have neurological issues of any
type, and some of them are very specific to TBI or ABI. So we're going to try to cover all of that, so that this is not just for the one or two kiddos that you might have in your caseload that has a
traumatic brain injury, but might be applicable to many more kids, as you go back to your schools.
We want to really hit some of the social interactions and the behavior interventions this afternoon. I don't know if you guys in BrainSTEPS get these referrals all the time, but as the Coordinator of
Mental Health in Cherry Creek, a lot of my referrals that came to me were primarily about behavior. "This kiddo is melting down," "This kiddo is aggressive." And underneath it, there was some other
concern for brain injury, or some other kind of neurologic [INAUDIBLE] disorder, but the presentation to me almost always came from teachers or parents about behavior, because that's the
manifestation, right? That's what rises to that level. So we want to hit some behavior, a little bit, and then, of course, executive function. Your kiddos that are having trouble with
problem-solving, or judgment, or decision-making which, again, kind of translates into behavior. We want to make sure we have a little time for that.
And then we were also asked to speak a little bit about special education in our criteria in Colorado. Lucky for us, I guess, in some ways, that in Colorado we had a pretty vague definition, and our
traumatic brain injury label fell under "physical disability" for many, many years. And then when I went to the Colorado Department of Education in 2010, they decided to open up their roles and
rewrite some of those labels. And they just happened to be there, and we said, "Do you think we need a label for traumatic brain injury?" And I said, "Absolutely. And I just happen to have one here,"
and then was able to put forward our medical documentation and/or credible history criteria that we use in Colorado. And so that's what we've now moved forward with since 2013, right? It's required a
lot of training in this state, because it really does open wide some of the kind of the diagnostic differentials, and put a lot of responsibility on our educators to figure out the differences there.
But we trust you guys to do that. And in Colorado, we just feel like if we can back you up with the foundation of why we made those decisions, you guys in the schools will have the tools you need to
make those decisions. So we'll present that to you and see how that works for you here in Pennsylvania.
And then case studies. So I know that's a huge agenda for today. Are there particular reasons why you guys are here, or things that you want us to hit that we can readjust for the morning or for the
afternoon to make sure we meet your needs before you leave today? And it's a very small group; very informal, so feel free to speak up. Heather and I are very willing to adjust, so -- anything?
>> For those of us who are new to that, what is BrainSTEPS? It sounds like [INAUDIBLE] --
>> Oh, BrainSTEPS.
>> Should we stop and have Brenda talk about BrainSTEPS?
>> -- familiar with that one.
>> So BrainSTEPS, basically, we have a Website, and it's BrainSTEPS.net. So in the State of Pennsylvania, we are starting our ninth year. We have BrainSTEPS teams that are brain injury school re-entry
consultants at all of the intermediate units. So our teams, like most of the people here are our team leaders. We have some team members also. There's about 280 consultants across the state, and
anytime any child has any type of brain injury that has occurred after birth, of any severity, at any point in time, you can make a referral to BrainSTEPS. We will come out to the school and offer
training consultation specific to that child's brain injury, also concussions that are part of that whole spectrum. If a student with a concussion doesn't get better in about four weeks, we just ask
for those kids you wait until around the four-week mark to make a referral, because most kids do recover before then. Also, it can be old brain injuries. So if a student has a brain injury when
they're one or two, and now they're 12, and the school is having issues, you can make a referral to BrainSTEPS. And you can make a referral right online at BrainSTEPS.net.
>> Thank you.
>> That's a good question.
>> Yes. Thank you, Brenda. We are actually wanting to get something like that going in Colorado, so we're picking her brain, as you guys do an excellent model here. And we'd love to have that in our
schools. It's just me and Heather over there.
All right, so shall we launch right in? All right. We were going to start this morning with just a video that kind of sets the stage for what we're talking about with brain development in general.
>> A lot of us are wondering, what is all this technology doing to our brains? I mean, we know that the brain changes throughout life based on experiences. In fact, watching this movie is reshaping
connections in your brain right now. But since we humans are the ones creating and using this technology, maybe a better question to ask is, how are we shaping our brains?
There's so much about the brain that we don't know. But there are some things we do know. You see, not long after we humans began thinking -- hmm -- we began thinking about ways to understand our own
brains. One strategy thinkers have used throughout history is to compare the brain to the newest technology of their day. The brain is a clock. A switchboard, a steam engine, a machine, a computer.
And we wondered, how can today's technology help us understand the brain in a new way?
So we use that technology to ask people all over the world, how do you imagine the brain? It was amazing, like all these neurons firing ideas and images back to us from all over the world. And it was
very clear. The Internet, the most advanced technological system in the world, is such a strong framework to help understand the human brain; the most advanced biological system in the world.
But then we thought about it a bit more. And since the Internet is in such a young, developmental stage, rapidly growing, constantly changing, forming billions of new connections all over the world,
then maybe a stronger framework would be to compare it to... A child's brain, which is in a similar stage of development; rapidly growing, constantly changing and making billions upon billions of
connections between different parts of the brain.
So here's the question - If we say that the Internet is in a similar developmental stage as a child's brain, then what can we learn by comparing them? Let's start with size. Obviously the Internet
seems like a larger entity than a child's brain. But what does that mean in terms of our analogy? We could say that a neuron in the brain would be like a Webpage in the Internet. So let's look at the
number of neurons in a child's brain compared to the number of Web pages on the Internet. Well, a human at any age has about a hundred billion neurons in the brain. But the Internet has 10 times
that, one trillion Web pages. So with this analogy, the Internet is bigger.
So then, which of these networks is more complex? We could say a synapse in the brain, the connection point between two neurons, is like a hyperlink -- the connection point between two Web pages. So
are there more connections in a child's brain or on the Internet? Well, the Internet has over a hundred trillion links. And an adult's brain has three hundred trillion links. But get this: A child's
brain has a quadrillion connections -- 10 times the number of connections of the entire Internet. A child's brain has more connections than the entire Internet. Yes, it blew our minds, too.
How is that even possible? Let's break it down. As we said, a baby is born with a hundred billion neurons. But those quadrillion connections -- they're not there yet. Those connections form at a very
rapid speed during the first five years of life; at seven hundred to a thousand new synapses per second. Those connections are created through every interaction a child has, and are important because
they form the architecture of the brain.
So every time you talk to and engage with a child, you're literally growing a brain. Connecting the different parts of the brain which allows for new ideas, insights and creative thinking. So each
moment of eye contact, each new word exchanged, each time you make a child laugh -- you are strengthening these connections. And since there are so many different ways to do this, we asked people
around the world, send us videos of your favorite ways to engage with the children in your life.
During these early years, a child's brain makes as many connections as possible. And then it begins pruning the ones that aren't used, and strengthening the ones that are; a dynamic process that
continues throughout life. But since a child's brain is activated by everything it encounters, it can also be overwhelmed, which causes stress. When the brain experiences stress, the body's alarm
system is activated. If the stress is relieved quickly, the system easily returns to normal. And while learning to deal with stress is an important part of development, severe situations, such as
ongoing abuse or neglect, where there is no caring adult to relieve the stress, leaves the body's alarm system activated, which can have serious lifelong consequences for the child. This is known as
"toxic stress." Toxic stress can lead to a body system set permanently on high-alert. It causes the synapses we use for learning and self-control to be pruned, while connections for fear and rash
behavior gets stronger.
While the brain can change throughout the rest of life, these early years are fundamental in building a strong foundation for curiosity, creativity and adaptability. And if we say that the Internet is
in the same critical stage of early development, making as many connections as possible, we also need to be mindful of how we're building its foundation. Just like every interaction creates new
connections in a child's brain, every email, tweet, search or post is creating and strengthening connections in our global brain, literally changing the shape of the Internet that we, as billions of
people all over the world, are developing together. And just as it's key for all the different parts of a child's brain to be connected to set the stage for the most insightful and creative thoughts,
it's key that all the different parts of the world are connected, to lay the foundation for worldwide empathy, innovation and human expression. And while we don't know all the ways technology is
reshaping our brains yet, we do know that every time we plug in, every person we follow, email or link to, we know it's affecting us.
So we need to be mindful of what we let into our brains -- always, which sometimes means knowing when to disconnect. Just as it's not good for a child's brain to be constantly over or
under-stimulated, it's not good for an adult's brain, either. For both the Internet and a child's brain, the connections we pay most attention to will be strengthened, while the ones we use less will
So how do we nurture both of these growing interconnected networks to set a course for a better future? By paying attention to what we are paying attention to. Attention is the mind's most valuable
resource. Every interaction counts. We all have the opportunity to shape the future of the world, and our future starts here.
>> So we're always asked to come out and talk about brain injury, right? But how can you start talking about brain injury until you really set the stage for what's happening in the brain, and that
would be a whole other lecture, take a whole day to do, so that was a nice little video to show how important it is in normal development, the connections that are happening, that we strengthen the
ones that we pay attention to, we prune the ones that we're not paying attention to, and we need to be very mindful about that. And so as we go on about what happens with brain injury, you can see
where there is a disruption in some of that, in some of those normal developing synapses and developments, and of course, therefore, that's what takes us off track to where we are today, trying to
understand that to get our kids to be as successful as possible.
So I'm going to go ahead and jump right into brain injury, and the definition of. So brain injury, when we talk about brain injury, there are a couple of different types of brain injury. As Brenda
mentioned, when we talk about a brain injury that has happened after birth, that that is an acquired brain injury. So in theory, there's normal development of all of those synapses; the brain is fine
up into the point of birth, and oftentimes, for a period of time afterwards; normal development with many of our kids before something happens that takes us off track. So we're not talking about
necessarily congenital kinds of issues where in development, prenatally, there are some concerns, and that again would be a whole different presentation.
So in theory, for what we're talking about, normal development in birth, normal birth and then something happened, a brain injury happened after birth, so that's an acquired injury. And within the
acquired injury post-birth, it breaks down to traumatic and non-traumatic, right? And traumatic brain injury, a TBI, is specially any type of injury that is an insult to the brain, usually,
theoretically, from the external force; so either a hit to the head and/or an introduction of poisons or chemicals that are outside, introduced outside, versus -- so non-traumatic usually is
connected with acquired brain injury, but that kind of also then goes into the category of there are other kind of more gray areas of gray in there, such as more like the chemicals, anoxic, stroke,
[INAUDIBLE] where there's lack of oxygen -- those kinds of things that are still after birth, but not an external force, okay? So we're primarily talking today about the things that you will see, the
changes to a child's development and learning post-birth, after an acquired brain injury, but for special education purposes, we're talking specifically about traumatic brain injury, okay, because
that's how the federal government looks at it.
In terms of fetal alcohol and all, that is more, again, on the congenital side. And while you might be thinking about many of your kids that have many of these effects and things that you can use in
terms of these assessments might also be good for kids with fetal alcohol, these interventions might be good for kids with fetal alcohol -- we're not specifically talking about them in terms of
acquired brain injury. That's more congenital. Right, anything you would add to that?
>> Just on the next slide. When we really talk about similar impacts, we do have an array of similar impacts across both congenital as well as acquired. So when we talk about the interventions that
we're talking about this afternoon, the assessments -- all of those might be applied in that, so that's just -- we want to broaden your thinking. We also want to talk about and just introduce you to
even a broader understanding of, when we look at ADHD, trauma, neglect, all of those kinds of things that you wouldn't necessarily put in a brain injury category, right, if you were talking about
traumatic brain injury especially -- some of these same kinds of thinking assessments, interventions can be applied to a much, much broader group. So we're challenging you to not only learn about
traumatic brain injury and that specific category as far as special education, but also be able to apply these learnings to a much broader group of kids -- all of our kids, so in some way or shape.
So that's kind of the context.
>> Thank you. And that's why the film that we saw was so important, because it's all really the same thing, right? It's all biochemical, it's all electrical. And so when you have trauma, when you have
mental health issues, bipolar, those kinds of things, they're going to be affecting neurotransmitters. Neurotransmitters are still going to have effects that are looking a lot like same kind of
interventions and assessments that we use for brain injury. Okay, so we're going to challenge you to think narrow, then wide, then narrow, then wide throughout the whole day, all right?
Okay, so this is just another way to look at the acquired brain injury definition, and within that non-traumatic and then traumatic brain injury. Okay, what are the most common causes of non-traumatic
brain injury? We had talked a little bit about that. We talked about anoxic injuries, which would be lack of oxygen, stroke, tumors, poisoning -- those kinds of things that were not, in theory,
externally -- an external blow to the head. And then when you look at the common causes of traumatic brain injury, this is how it breaks down developmentally, with physical abuse for the younger
ones, the infants. And we also know that today as -- there's another name for that. Anybody give me the name for what physical abuse is in infants? What did you say?
>> Abusive, yes. I heard it.
>> Abusive head trauma.
>> Abusive head trauma, yes. Also known, though, as --?
>> Shaken baby syndrome.
>> Shaken baby syndrome, which is a whole, again, different concern in our environment. And many of the proponents, of the ones that are doing the research in shaken baby syndrome would say, you know,
we should stop calling it "shaken baby syndrome," we should call it what it is. It is abusive head trauma. "Shaken baby syndrome" sounds too gentle. It causes diffuse damage in a developing brain. So
that's the most common cause in infants. As you continue on, toddlers falls in abuse, young children, passengers in cars, school age, bicycles -- again cars, pedestrian, that kind of thing -- and
then with adolescents, driving and motor vehicle accidents. And so you can see how this breaks down developmentally by age. And the reason we bring this up is because when you are starting to work
with your families and trying to assess traumatic brain injury, if you have a child who has a normally developing brain and then has a normal birth process, and has, in theory, some period of time of
normal development, then this happens in their life with a motor vehicle accident or a bicycle accident -- that can be quite traumatic for the entire family, right? It causes quite a disruption, and
a grieving process for the entire family; that the family has to kind of learn a new normal. And that becomes a big concern in sort of the whole assessment, because whether right or wrong, a parent
always carries with them this extra load of guilt and concern for what happened, even many times when it's not their fault, right? Motor vehicle accidents happen. A child goes out on their bicycle
and something happens to that child.
But we as parents always say, "Well, I wish I could have prevented that," or, "If I hadn't bought that bicycle," right? Or, "If I hadn't left them at that babysitter's." You know, those kinds of
things that carry an extra load of, for our parents -- this is not just a parent coming in saying, "Doctor, I'm concerned about my child's development, what do you think?" There's this added
component to it. And we need to be especially sensitive to that as educators, because that's going to, of course, bring up all kinds of other concerns. And then what ends up happening then, for many
of our families and for many of our parents, is that there -- sometimes because there is so much stress and trauma around the introduction of the injury that we, as parents, hope that this will not
have long-lasting effects, so we give it some time, or the child goes into the hospital for a couple of overnights, maybe a week, maybe a couple of weeks post-brain injury after this accident, but
begins to make some nice recovery, and ends up getting sent home in a couple of weeks. And as parents, we're saying, "Wow, this looks good, I think we're going to get back to where we were." So we're
constantly hoping that this is not going to have long-term effects.
And what do the doctors tell us in the hospital? "You need to give this a couple of months, or anywhere up to" -- how many years? Two years to see recovery after a brain injury. So we, then, as
parents and as educators, we are saying we're going to continue to support this child and watch for recovery, which does happen very rapidly for some of our kids, but not everything necessarily comes
back to the same place it was before. And then we have these splintered skills. So what ends up happening is that between the period of grief and the time of recovery, time goes by. And when time
goes by, we as educators, then, we have a student who maybe had an accident in first grade, but now we're in sixth grade, and we're really concerned about learning, behavior, executive functioning
for many reasons, and the timeframe is too far now to just say, "Oh that was from that injury in first grade." That becomes the issue you guys have with medical documentation, credible history,
right? It makes all the sense in the world for this type of an injury why we have that delay; why we, as parents are hoping and watching for change in recovery, because we are seeing it. And why our
doctors say, right about in here -- how many of you guys have ever received a report from the Children's Hospital around here, whichever side of your state -- you have two Children's Hospitals, right
-- that says, "Mild brain injury, discharged home, should be fine." Have you ever seen that?
And then they come into your classroom, or years later, and they're not as successful as you would hope they would be, behaviorally and with executive functioning and with learning. Anybody have
received those? Because the medical doctors have their own category of how they rate brain injuries; mild, moderate and severe. And basically, what they are talking about is the specific factors of
-- from the mechanism, how the child looks at the time of the injury, and how responsive they are physically with stimulation, with eye gaze, that kind of thing. And for them, having the child come
into the emergency room, who then begins to make a nice recovery and walks out of the hospital is success to them. They've done their job, and they're very happy with that, and we are, too. But what
they're not thinking about -- so in that case, that's a great recovery, maybe that's a mild TBI, according to their scales, the Glasgow Scale, but as educators down the road, functionally this child
is struggling and not the same as they were before. That's not necessarily a mild traumatic brain injury to us. It has moderate to severe effects. So you can't just look at the medical classification
of mild, moderate and severe and say that's the same for us. But when this child comes home from the hospital as a parent, I see mild, and I'm thinking my kiddo is going to be fine. And not until
down the road do I begin to wonder if this, perhaps, is now related back to that brain injury. And it primarily happens when this second peak of executive functioning happens.
So in normal development, we have -- this is just the myelination of the brain cells within different parts of the brain, and they're constantly developing, as it said in that video. But what ends up
happening in the frontal lobe especially, which is right in here, there is this great period of myelination of the cells within the frontal lobe early on for our little guys, because they are
learning things like cause and effect, how to delay gratification, putting themselves to sleep, calming things - so all of this that happens in the frontal lobes has to do with our personality, has
to do with our ability to wait and delay, has to do with learning the rules of executive functioning, of how to function in this world.
So we have this really great burst of myelination in those early years. And then over time, that becomes less of a focus in the brain. Other parts are myelinating; language, math skills, all kinds of
other things. You would see peaks in other parts of the brain, and a bit of a kind of a lull in the frontal lobes. And then when you get to about the middle adolescent years, we see another spike of
myelination of those frontal lobes, because that's when, again, we really need our young adults to start thinking things like, if I get the car keys, will I make good decisions behind the wheel of
this car? Mom says be home at midnight, I need to be home at midnight. And so all of those things that we start to move towards independence is based upon good, executive functioning. So you really
see executive functioning come in again kind of later into the later elementary, middle school and high school years. And if there's been an injury in between, and we don't get the second peak of
myelination in the frontal lobes, and we don't end up building in things like good judgment and being able to delay and attend, that's when you begin to often say, hmm, okay, the injury was in first
grade, but now we're in sixth grade, and we're really struggling with organization initiation. It's because it's becoming very apparent with this second peak that that myelination and executive
functions did not happen.
So when we got -- when I was at Cherry Creek, we'd get many calls from teachers and parents saying, my child had an injury in first grade, here we are in middle school. I need you to come out and
assess because his brain injury is getting way worse, because he cannot get from locker to classroom, he cannot get home by himself and be home for 15 minutes by himself. He's not making friends,
he's not learning as well. And usually, when we would go out to do these consultations, it wasn't that his injury was getting way worse. Brain injuries, for the most part, get better over time;
rapidly in the beginning and then a bit of a plateau. But what ends up happening is that the demand for independent executive functioning gets higher as you get older, right? So when he was in first
grade after his injury, he comes back to school and he's in one classroom with one teacher, who is acting as his frontal lobe? His teacher. Do this now, do this next, put this in this bin. And at
home, you know -- put these shoes away, get your socks out. But as you go into middle school, we expect them to have more ability to organize and initiate, right? So we begin to pull away the
executive functioning, and then it becomes apparent that this child is struggling because the executive functioning did not develop on its own. And then, of course, in high school, you have seven
teachers, right? And you have all those things to juggle. So it's really apparent; if it wasn't in middle school, it becomes apparent in high school. It isn't that the brain injury has gotten worse,
it's that the demands that we have for this student have increased, and they haven't kept up with that, because of that disruption in that second peak of executive functioning. So we have to go back
and teach executive functioning, which Heather will do this afternoon.
Okay, so statistics -- so why is this such a big concern at this point? Well, brain injury has always really been a concern; it's a leading cause of death and disability for children ages one to 19,
but it hasn't really been on our radar for many, many years. And for the Centers for Disease Control, you can see more than 60,000 children are hospitalized every year with this, with moderate to
severe brain injury. Yet when you look at the kids that are being discharged from the hospital, our research has shown that only two percent of them are being discharged with any kind of a label,
special education label, back to the schools, to you. And again, why is that? It's often because what we see within the first couple of weeks of hospitalization, we don't expect it's where they'll
be, so we discharge them back saying they're going to make such recovery over time, just give it time. And so then the timespan happens, and then we have a difficult time going back and saying, now
this child needs special education.
So when you look at that and you look at the overall numbers in the U.S. Department of Education, traumatic brain injury has always historically been a very low-incidents disability; not because we
didn't have kids with traumatic brain injury. In fact, when you start even looking at the kiddos with the very mild brain injuries -- now we call them "concussions" and all the hoopla that's going on
with concussion -- that number just significantly increases, right, into the millions. Not that those kids are going to need special education, but again, there's a question. They've had an external
blow, so that raises the question.
So we as a group of specialists in brain injury haven't really had an audience to speak to for many years, except here in Pennsylvania; you guys were way on it ahead of anybody else. But for us, you
know, we have been aware of this, but not really being able to go out and get our educators aware of it. In the State of Colorado, we didn't have a special education label for brain injury until 2013
>> It was 2012.
>> Yes. So how can you train to a label if you don't have it, right? So of course, therefore, we're missing a lot of kids. And it's all of the things that we had talked about with the ever-evolving
recovery and with the grief that goes into it, and our parents wanting them to get back to normal and not having a label for it, therefore, there's under-identification. And so therefore, the time
period gets too long.
If you have under-identification of traumatic brain injury, you have apparent low incidence. And if you have apparent low incidence, then you don't need to train to this, right? Because in your career
as educators, you might see one or two kids with a brain injury, that's all. And when that happens, just call Brenda, she'll come out and help ya. That's kind of how we treated this up this point,
right? So if there's a lack of awareness because we haven't been training you guys, then of course there's no money for research or training or supports that we put out there nationally, as well as
trickled down to you guys, to parents, to teachers, to general ed teachers. And so if there's lack of training, so what ends up happening to our kiddos? Well, we would take care of them. We wouldn't
say, well, we have no training in our schools; therefore, if you have a child with a brain injury, you get nothing, we would say we would find what this child needs. And if the manifestation was
primarily behavior, we would put them in our socioemotional behavior programs. If it was primarily learning, we'd put them in our learning programs, right? Speech, language did a lot to pick up a lot
of these kids and support them.
So I never worried that our kids with brain injuries didn't get their needs met. They were picked up by really good educators in other disability-eligibility labels. But that didn't necessarily mean
that they got exactly what they needed for their traumatic brain injury, okay? They were loved and they were taken care of, but under different labels, and therefore, that then just perpetuates the
cycle. You know, if we don't have numbers of kids in special education with traumatic brain injury, then again, we're not going to start to come out and train you guys. And this goes on.
And in the end, what happens? Well, the kids that got services under other labels, they were well-taken care of in many, many ways. But our concern is, over time, is that at some point, your
interventions for learning disabilities, your interventions for behavior, don't work as well for every kiddo with a brain injury. And at some point, you need to again get narrow. You can get wide,
but you have to get narrow. You have to be able to go back and forth and know what is unique about a brain injury, and know when to apply what for a kiddo with a brain injury. So what ends up
happening is that when you look at the research retrospectively, if you go back and you look at the surveys of adults and children in criminal systems, almost all of them, 87 percent, 97 percent,
have had -- can report at least one incident of brain injury that potentially could have taken them down this trajectory towards criminal behavior. If you look at homelessness, 30 percent; substance
abuse 60 percent, mental health 60 percent. Now, keep in mind, this is retrospective research. This is not that if you had a brain injury, then you were going to go on and be homeless. But when you
went backwards and asked, there was something on a survey that was of concern to us that said perhaps something went off track. This is where the trajectory changed, and therefore, we weren't
supporting our kids the way we needed to. Maybe we did the best we could under LD or BD, but at some point, maybe it wasn't enough.
So when you look at that, our concerns, of course, for mental health are significant with a number of depression, anxiety kinds of disorders that we have post-injury, when you look at one third of TBI
[INAUDIBLE] experience emotional problems between six months and a year post-injury -- so now, with our research looking forward longitudinally, we are tracking that forward and finding that the
emotional and the behavioral and the social impact is concerning as we move forward, not just retrospectively. And in terms of the concerns and all of the work that's being done for depression and
suicidal behavior, of course we don't want to have this kind of information and say that we don't want to intervene at this early level, okay? So and, of course, as I said, primarily your referrals
in terms of behavior are going to become -- they're going to rise to the level of a behavioral concern, and you're going to trickle it back down and find that perhaps there's some -- a concern for
brain injury earlier on. Question in the back?
>> Yeah, I'm really glad that you're bringing this point up, because it's one of the biggest challenges that I find. So you have a child who had an early brain injury. They recovered, and seemingly
doing well, and then as you said, they hit middle school and things start to fall apart.
>> So as the BrainSTEPS team member trying to go in and educate the team that this can happen, the problem I run into is, we have no medical support at that point because they've been --
>> -- dismissed from the concussion clinic, or, you know, the doctor's saying, "very okay," so I'm coming in saying, well, you know, what we're seeing here is very possibly related back to the head
injury. But the educational feeds in the schools don't really want to hear that. I don't know if you've had similar experience, or how you felt?
>> We do have similar experience with that. And, in fact, it was the field in Colorado that had recommended to us that we consider exactly the option of credible history as we move forward for looking
at special education, because of those kinds of questions. But it really does bring up a lot of gray area. And so, what I have done is laid out all the concerns that you guys have and that we have.
What we will do after the break is to begin to get into the credible history -- how we dealt with it by credible history. And we'll actually walk you through the way we do training for our educators
in Colorado to help piece, pull apart what those questions and concerns are. There are legitimate parts to each of that, I mean, it potentially could be that. But it doesn't necessarily mean it is
that. And how would you make a case for it being or not, right?
>> Let's get going on some -- a little bit more of the nitty gritty in the content. So what, again, your handouts are now up, so if you do have a device and want to pull those up, you can log on. So
the model, or the framework, that we use in Colorado is the hierarchy of neurocognitive development that we've kind of adapted and called our own in Colorado, and that's what you're looking at here.
As far as the hierarchy goes and the pyramid or the triangle, or the whatever -- I stayed away from all RTI colors, as you can tell, so that there will be no confusion here. But these are the typical
impacts -- not an exhaustive list, obviously, but the typical impacts highly sensitive to brain injury. So when we talk about the neurocognitive hierarchy, this is what we're talking about.
We also want to use this as a frame to make sure that people are really drilling down and looking at skills before we jump to higher order. So when we look at all of the fundamental -- so this orange
layer, all the fundamental processes in our brain that are absolutely integral for learning, but they're also absolutely integral for behavior, you must have all of these things intact and working in
concert for all learning and all behavior. So that's what we use for educators to make sure that -- because we always talk about behavior, right? That's what we get referrals for, is behavior. So
that's jumping to that higher order processes without even paying attention to fundamental or intermediate types of skills or processes in the brain that there may be gaps in, especially when we're
talking about brain injury.
So this is the framework that we use, and it's interesting, since the brain injury -- since the TBI special education category has come to be in October, 2012, we've been talking about this and using
this as basically our underpinning of all of our training. We have had many other groups in Colorado jump on board with this, so hopefully it'll be a Colorado thing versus a brain injury thing, which
would be great. But we've got all of our facilities groups using this; autism is looking to use it. So hopefully it'll -- and we've got -- yeah, mental health using it. So we've got some momentum
from the brain injury world that's been spread, so that's a good thing.
So when we take a look at this and we talk about these processes in our brain, and the sensitivity to brain injury, when you talk about the fundamental level, attention processing speed, memory and
sensory motor are the ones that we talk about being absolutely fundamental, and they're also very highly, highly sensitive, probably the most sensitive, to brain injury. When we look at the other
levels, the intermediate level, all new learning -- so after a brain injury, we have that typical development, right? After a brain injury, new learning is different, and may be affected. Now, I'm
saying these are the typical ones; you're not going to see every single kid dealing with these types of issues in processing. You're not going to see every type of processes issue in every kid. We
always talk about in the area of brain injury, if you've seen one student with brain injury, you've seen one student with brain injury, right? Because every single one is different. So keep those in
mind, as well.
But when we talk about the intermediate processes, we're talking about all new learning and all language, language development. And we never, never leave social pragmatic language out of that; we
always talk about expressive and receptive, but please, please include -- and those SLPs in the room are probably shaking their heads -- please include that social pragmatic piece, because it is
absolutely key in the world of students growing up and trying to learn environments, the untold rules and how to get along and how to converse, and all of those things -- so very important piece.
Then, and only then, should we look at higher order. So the blue level is that higher order thinking. That socioemotional competencies, as well as all executive function. The executive functions,
depending on who you have -- and I know you've had some great training around executive function in this state, so that's wonderful. The ones we've highlighted are the five up on the screen. So we've
talked about planning, initiation, reasoning, mental flexibility and organization. Again, not an exhaustive list, but some key areas that we've chose to really drill down and highlight, as far as
brain injury and its impacts.
Another thing, and it was illustrated with that previous slide with the wedges, the red and the blue wedge of typical development, and then that injury and drop-off and skills coming back to keep in
mind, and a hallmark of brain injury is unevenness. So after an injury happens, things come back, and things can come back very rapidly. Those skillsets and those processes and talking, and all of
those things -- prior learning, all of those remembrances, and things can come back really quickly. But they usually come back unevenly, or splintered. So unevenness is a hallmark of brain injury
that we need to keep in mind. And it's also one of those unique things to brain injury when we think about kids responding to interventions, so you could have Read 180, or some type of intervention,
and if you've got a student with a specific learning disability, it could be exactly what that student needs. If you've got a student with brain injury, it could be hitting the mark some days and not
others. Or a beautiful behavioral plan that's working well one week and completely not even touching, as far as intervention, the next. That could be unevenness.
So those are the things -- and that's one thing by way of brain injury that we need to keep in mind as educators, and help teachers understand because unevenness is one of these most maddening things
a teacher can deal with in class, right? I ask you a question on Monday, you're able to give me the answer and retrieve that information. I ask you the same question on Thursday of that same week --
it's not there. Could be unevenness. So when we talk about choice, we talk about behavior, we talk about, oh, you're just being woeful, you're being disobedient, whatever we want to call it, it may
not be. It may not be choice. It may be that that brain and those connections are not being made exactly the same way as they were on Monday. I'm not able to do the same path and retrieve that. Or my
processing speed is way off, so I am a two-minute kid in a two-second world, right? So there's lots of different things that can be going on at that time. So those are something that as far as brain
injury specialists or experts in our field, we need to help the rest of the teaching staff really understand those things, rather than just write up a referral for behavior, right?
We are going to get a little bit more active now with these, and you guys are going to teach each other about these, because we know you know it, and you have them on your tables. You've got an
envelope that looks like this, on your tables. What you're going to do is, you're going to take out all of the little strips of paper. They represent all of these domains. Put them in order --
fundamental, intermediate and higher order -- we're going to start with the fundamental. So when we divvied those up, there's only going to be four, so you guys with more people around the table,
that's great, because you'll all get a turn and then some of you will get more than one turn, to do a jigsaw teach. So when we get all of our fundamental domains in one area, divvy those up, and
teach each other about your domain that you've got on your strip of paper, okay? The definitions are there, you can throw in examples of the kids that you know, how that might show up. Whatever you
need to do. We're going to keep these really quick interchanges, so we can get onto some other things. So right now, open up your envelopes, and we'll put them in order. And then we'll start teaching
So you guys now are experts on the domains, right? You guys have all of the definitions in front of you. They're also in your handouts. But if questions come up, don't hesitate to ask. I wanted to
point out a really great resource that we use in Colorado, and it's actually been used across the nation, is the Colorado Brain Injury in Children and Youth manual. It looks like this. Have you guys
seen it? This is actually a little bit big. This is the Colorado Department of Education manual. This is. (Laugher)
>> We'll just describe it to you.
>> It's kind of big, and has a brain on the front...
>> I don't know if I can. This is the Colorado Brain Injury in Children and Youth manual for educators. It is on the CoKids Website, which is CoKidsWithBrainInjury.org.
>> Dot com.
>> I'm sorry, dot com. I don't know where "org" came from.
>> I'm sorry, what was that?
>> It's a free --
>> Thank you.
>> It's a free download on the CoKids Website, and it's a free download off the Department of Education Website as well. That has everything color-coded associated with this hierarchy, so the whole
orange section are all of the fundamental, the green section intermediate, et cetera. So we have dedicated full chapters to the blue area, which is that frontal lobe, right? Mainly that frontal lobe.
I had a really good question come up from this table, as far as, are we going to go over this separate lobes of the brain? We used to do that, we used to start with kind of the neuroanatomy, and what
parts of the brain kind of primarily function with what types of domain areas. But there's so much integration and there's so much linkages and connections that we don't want people to think in those
categorized terms of, if I get an injury to my temporal lobe, I'm going to be affected by way of language. It's not that clean. There is not a one-to-one ratio. So we moved away from that, thinking
we just need to go into the impacts and how they integrate the typical impacts -- all of those things that could be doing on by way of brain processes, and how an injury might interact with those
brain processes in a much more general and integrated way. So that's why. So that was a great question.
>> You got the unevenness?
>> Yes. And let me go back here. So how many -- where did you guys put unevenness? Where is that? Overall. Right. Anyone else put it with something really specific and have an example? So it was just
everywhere, overall. Because that was a little bit of a -- we threw that in, because we definitely want you to think about unevenness and learn about that, and how in each one of those domain areas,
it could be interacting. So we definitely wanted to throw that in, but it's not on this, so I know people were, like, well now, where does this go? So good, you're critically thinking about these
things, and that's exactly what we wanted you to do.
>> Okay, let me stand over here, because I'm trying to not have Tim move the whole camera around. Who in here still has their hierarchy from bottom to top? Which table? Anybody? Do you guys back
>> Okay, so let me give you an example, okay? Fourteen-year-old, your 14-year-old son, you said, "I want you to meet me at the school. I'm picking up your sister." He was home half day. "I want you to
make sure that you let the dog out, let him go to the bathroom, put him back in before you leave, turn off the stove, turn on the air conditioner because it's going to be hot when we get back, lock
the door behind you when you leave, and meet me at your sister's school, two blocks away," right? Some things that you'd ask a 14-year-old to do. Okay, that table back there with it all in order --
take the memory out. Pick up your memory, and take it out. What happens to that higher order thinking, if you remove that memory on the bottom? It's wobbly, right? Your son does not end up at that
school. Or if he does, the air conditioner's not on, the garage door is up, right?
>> And who knows where the dog is?
>> You're angry, right? And it's behavior. But it could have really been about memory. And do you see that the bottom level, the foundational ones, are so important to really understand and help your
families and your teachers understand, or we can't build the rest of it. Everything becomes wobbly if we have one or two areas where the brain injury has impacted on that bottom level.
I'm going to add one more thing, because I've heard this question come up already today. If you have a kiddo who is having a tough time watching the teacher, staying on task, dividing their attention
or shifting their attention from one thing to the other, or inhibiting an outside influence, which is an intentional issue as well, so that's your attention domain, where does that fall on yours
right now? Is it the bottom or the top?
>> Attention at the bottom.
>> Attention is the absolutely bottom of your pyramid. If you don't have attention -- that is your foundation -- the rest of it doesn't build, okay? Inevitably I hear family members, or doctors say,
or teachers say, "I think this kid has an attention deficit disorder." I am really cautious about that, because almost every one of our kids who has a brain injury or a neurological impact of almost
any sort, it can almost always have some impact in attention. And then, a couple of years go by, and what do we know? We know attention deficit disorder, so we tell the family that, they go to the
doctor, they get thrown on medication -- stimulant medications on top of a brain injury will do -- no one really knows, right?
>> All kinds of fun things.
>> Sometimes they work pretty well, lots of times they don't. So I'm very cautious that if I know that there is ever a diagnosis of an attention deficit -- or ever a diagnosis of a traumatic brain
injury, it in and of itself removes from my mind the diagnosis of an attention deficit disorder. Could they have attentional issues secondary to a brain injury? Yes. Can we treat that? Can we support
that? Can we maybe even in some cases under very careful medical management manage that with medication? Yes. But they don't have an attention deficit disorder. That's different. And if you remove
that bottom foundational level, you really will have a wobbly rest of it. Okay? Thank you.
>> All right. One more thing around attention that we always highlight is inhibition. Inhibition is a process that's associated in that attentional world, if you will. Inhibition is the breaks. I
don't have breaks to stop what I want to say, what I want to do, whatever. So it's the blurting out, it's the no-filter, when things come out of my mouth, I have not even thought about them first. So
that is one thing that we see a lot. And that's also one of those things that's highly prominent in the world of ADHD, is not having the ability to stop yourself in doing that. So that's another
piece of that attention that's really, really important when it comes to learning and behavior.
So when we go through all of these, which you guys all now know, when everything works in concert beautifully, and there are no gaps because we've done a great job as educators in filling in the gaps
and teaching actual skills around those, we get that overall, that very tip of the triangle that's represented in purple, is that overall functioning. And what that does is, when we talk about
learning, we talk about all of the achievement, academic skills. State assessments are coming together, we're able to remember all of those things, and we're able to achieve and show what -- and
demonstrate what we know. But it's also about adaptive living, and how all of the worlds and communities and arenas and environments that we work, live, play, act in, are all integrated. And we're
able to do these things day in and day out, and have some good judgment and reasoning, and all of those things are working together. Memory -- all of those things are working together. So that's kind
of that framework that we want you guys to use as a jumping-off point, okay? Do you have any questions about that piece?
All right. We are going to jump in now to our special education category and our criteria. So when we look at this particular framework and talking about acquired brain injury, anything after, now
what we're really talking about is special education categories. So we're really zeroing in, narrowing it down to only traumatic -- physical blow, okay? So all of those domains we just learned about
are really applicable, but now we're going to apply them just to the traumatic area.
So when we look at the IDEA definition, which you guys are very familiar with, because I think it's your exact definition, right, in Pennsylvania? Here we are with that. So we're not looking at
congenital, we're not looking -- we're just looking at the physical part of traumatic brain injury, the physical blow. And when we look at ours, which is ECEA in Colorado, the underlying things is
what we've added, because Colorado, ours have to be different. We're a local-controlled state, so we always kind of tweak ours. And like we said, traumatic brain injury is new as of October, 2012 for
us. So we took the IDEA, made it our own, added a couple of things. And do you notice anything when you go through, especially with the ones that are underlined? They're exactly the domains you just
taught yourselves about, right? So that is our criteria. So that's we did in a very intentional way. And we'll go into it further.
What we have on the CoKidsWithBrainInjury.com -- and that's here, here we go, there's the Web address -- that not only has the manual as a free download, but it also has this flowchart in the section
that is all about special education identification process. So this flow chart is a clickable chart; everything yellow you can click on and go to actually the tool that we use, and/or the information
that we consider. So this flow chart is a really good resource, and we'll be walking through it. So our definition says to be eligible as a child with a traumatic brain injury, there must be evidence
of the following criteria: Either medical documentation of one or more reported by a reliable and credible source, and/or corroborated by numerous reporters. So when we talk about medical
documentation of that, if parents walk in with medical documentation, we're golden, right? We usually have a lot of information; we know about the injury itself, the incident itself, the mechanism of
the injury. Parents usually can recall more details and give you all of those details about exactly what happened. And this is a wonderful way to establish the medical documentation, so we have an
actual incident, and it's documented. We already warned you about the CDC classifications of severity rating and the mild, moderate and severe, and not applying those directly to the educational
world because they're not always a good match, so that's just a reminder. But when we look at using our criterial and having a medical documentation, we always want to corroborate it as educators.
What we use in Colorado to corroborate that finding is the brain check screening tool. It's a tool created out of CSU, Colorado State University, with research in and around Colorado. It has been
proven valid. It has been proven reliable, and it has been proven specific to brain injury. So when we go through and gain that data -- and it's also given to parents for them to self-report, so it's
not us coaxing or guiding in any way, shape or form. We already have the medical documentation, right? We already know there's an incident. We already know that a brain injury has happened. Now, have
we met all of our criteria? No, because we've got lots of work to do, because it has to have educational impact, too. However, this is what we're corroborating, and for our justification, and for our
documentation, this is the parent's voice in that whole packet of documentation. It goes back through the actual incident, but then it also gives you more information about impact. It talks about
learning, it talks about behavior. So we have, from the parents' perspective, exactly what they're seeing by way of impact, okay/ So this is what we teach our teams to corroborate even the medical
documentation. We haven't even gone to credible history. But even medical documentation -- so where we can justify as a school team with the parents at the table that yes, we are going down this road
of traumatic brain injury by way of special education.
So in that flow chart, we are -- medical documentation, we jump down here and we do that health history and brain injury screening. And that's the brain injury check screening tool right there that I
just talked about. So obviously, part of our data collection is full health history. We want to involve nurses and social workers and psychologists, and all of those folks that are interacting with
parents to make sure that we really get a good understanding of that health history for that particular student. If there's been more than one brain injury, we want to get that health history and we
want to be able to go into detail about every single one, and really drill down to those skills as far as what's going on.
In the credible history part, it's a little bit grayer, right? We have a hard time sometimes connecting those two dots if we don't have that medical documentation. When we talk about the gold standard
of credible history, we're talking about structured and in-depth interviews. We are going over this information in a very deep way, so that we get details about now only the incident and the
mechanism of injury -- fell off the bike, hit head on the concrete -- whatever the case may be. But we're also going into what, when, how, how did you respond, all of those things. So this is the
gold standard of credible history. It is a new learning for our school teams. I always, always say if you can't justify your decision-making in a court of law, then don't justify it in a school.
Don't go there, if you don't have a recorded incident. So my gut tells me something's there, but mom, I just can't get anything as far as by way of a reported incident. I'm not getting anything, that
they fell in the playground, nothing's happened by way of a car accident. But I know something's going on. I know it. I know it. I want to go down this road of brain injury -- don't do it. If you
don't have a reported incident that you can then delve deeper into, you won't have a leg to stand on. Now, do we do special ed and do we do needs assessment? We do interventions by way of appropriate
needs? Yeah, absolutely. And I'll step over here and I'll put my congenital hat on for a second -- not traumatic brain injury, right -- if I have the gut feeling that fetal alcohol or substance
exposure happened prenatally, I may never have that bit of detail, right? I can't go there. But can I go there by way of meeting needs? Absolutely. And do we, as special educators? Absolutely. We do
what we need to do, we get the data we need to get. We make the best fit as far as the special education process, and we move on. So please be cognizant about credible history and make sure that you
can justify your decisions as a team, as full team with parents right by your side in that team process to go further down this road.
>> I have a question. So in your definition on the slide before this --
>> -- where it says, "significant history," so I think that's really important, then, because this -- I know we get a lot, the concussions. "Well, my kid had a concussion when he was four, but I don't
have any medical documentation." And now he's a senior and needs accommodations for math. So "significant history" would mean one or more traumatic brain injuries. So there must be a reason why your
state quote -- "one or more" -- so maybe more --
>> It could be one.
>> -- could be multiple concussions --
>> -- or one concussion, if we're just talking about concussions, I'm just kind of walking through this. But there would have to be a pattern over time, it doesn't just pop up?
>> There could be a pattern. But I want to go back to this last bullet, right here. Pre-injury versus post-injury. So I'm -- four-year-olds, is that what you said?
>> And I have a concussion. And I'm a spunky little four-year-old, even before I hit my head, right? And how much difference in behavior, in my sleeping patterns in my eating patterns, in my ability
to emotionally regulate, in my ability to call myself, in my ability to hold back before I just go into this rage of temper tantrum, whatever the case may be -- is there a pre-post difference? That,
to me, is significant.
Now, no one ever gives us the definition of "significant," right, when we're talking about IDEA. It's, like, "reasonable," "significant" -- they throw all these words out, and we do too, of course.
But that's where the expertise and the ability to have that structured, in-depth data collection piece and conversation with the parents or grandparents, whomever was there, whoever knows this child
and has lived with this child to really get a clear understanding of pre-injury behavior and functioning versus post-injury. If there is no change after a few weeks, whatever -- maybe for a few weeks
there was some changes in sleeping and some regulation issues, or whatever. But kind of back to the same baseline level, when we talk about pre-injury functioning level -- I'm not so sure that would
be significant for me to stand on, by way of a decision that says, yep, we're going down this federally-mandated law, legal process, to say, yeah, we're talking about TBI. So that's a really key part
of that whole process. I'm getting the history, I'm getting the story, I'm getting all of those details about functioning, both pre and post. And there's a way that we can actually compare that data
and see if there's a difference there. Yes?
>> I'm wondering, sometimes there's a span of many years. So as in Brenda's example, the parents reporting the child was injured at two, now they're 16, you know, in advanced level math and they're
having difficulty, and their parent wants to cite the brain injury, the concussion, as the possible cause. Would another way to decide that, or look at that, if it's only one class-specific, like to
me that might be a red flag -- they should be having perhaps some difficulty in multiple areas, not just in the math class. Now, math might be presenting a certain -- be taxing to some of these areas
more than another class.
>> But I would think -- would it be that, what was just on one specific class, with that many --
>> Well, perhaps -- I think when you're looking at it, you're talking about it shouldn't just emerge in one specific class. So if you're looking and you're doing an interview, if the student has been
-- if there's been issues, chronic issues in terms of learning with regards to mathematics prior to the specific class, that would be informing your decision.
>> Right. Are we seeing patterns?
>> Right, yes. Exactly.
>> And I'm also putting my detective hat on and trying to find if there's patterns. It could be showing up in English or in history or in whatever, but it's just not at the same level, or in a totally
different kind of way that the teacher is dealing with in a totally different way, if that makes sense.
>> Exactly. I guess the only thing I would add to this whole discussion is that you guys are creating a body of evidence, during this time. You're trying to figure out what's going on during this
question. And this question comes up all time, also not just with difficult math classes, but in manifestations. So as the coordinator of manifestations for my school district, I would get in a
meeting, and at 16, we're going down the road towards expulsion for this behavior. But oh, by the way, at four, this happened. And then we have to look at this whole thing as well. And the way, I
guess, I would see it is, back to that question of significant, you know, the kinds of questions -- you know, you're making a good case. Like, is it across the board? The kinds of questions I would
ask the parents, if you are really wanting to say that this is related to this at four years of age, can you tell me that there were ongoing issues in school? What did his fifth grade teacher say?
What did his sixth grade? What was his middle school time like? What about behaviorally? Was there ever a teacher that had concerns? Did you as a parent have concerns? Did you as a parent have enough
concerns about this potential injury at the age of four that you held your kid out of all sports through their whole middle and high school years? Because you know, if you really did, wow, I'm going
to -- that's going to weigh heavy in my decision. If you didn't, this kiddo's been running around -- so apparently you didn't have enough concern about this injury at four. Did you have concerns
academically? Did teachers ever bring this up? No. Nobody ever did. Did you have concerns as a parent that you ever brought this up to a teacher? No. Then that's suspect to me, again.
One class versus many classes -- the thing that always gets my kiddos at the age of 16 -- driving a car is hugely -- that is a huge privilege that requires executive functioning. Did you ever have
concerns about letting your child drive because, wow, he had a brain injury at four? You're telling me he had a brain injury at four. No. I never concerns, I let him go out and run around with this
friends, I never had concerns to let him drive, then this is a bit suspect. It is a bit convenient. So I'd try to make a case for that, but in a way where I'm just collecting the facts, ma'am. I'm
just asking you to document for me, and what I generally will find is there is no connection between here to here, until it became convenient to make this connection. And that's what you're looking
for, both in terms of either making your case that there is some pre-post, or there's been concern all the way, or there isn't. Okay, so make sure not only the academics, but hit them where it
matters. And that's going to be about the driving and the staying home by yourself, and all of those other privileges that kids get, that I'm sure you've given your kid before you were worried about
this injury at four.
>> Not to mention this - We have had some level of maturation and myelination going on. But if we're talking about a high schooler, we haven't hit this. Or maybe we're in the middle of it -- we
haven't even hit -- and remember, this is typical. This is typical development, not even with a brain injury. So we still have a lot of development to happen, to do. There are still lots of things in
our brains. And if we had an updated version of this, which I think we should contact Savage about, because he needs to update this -- because it goes through our twenties. Our executive function,
our frontal lobes, are developing well into almost 30 years old. Are we developing, or fully developed our frontal lobes of our brain? So put this to 29, and we might be touching this, all right? So
lots of things to consider when kids are struggling with executive function in high school, with reason they're struggling. Yes?
>> Do you have somewhere, I mean, you point out some great questions to ask of the parents when they bring up that scenario from the four-year-old to the 16-year-old, because that comes up quite
frequently. Is that of the brain check screening tool? Those questions? It would be great to have some of those questions on hand. I mean, I took some notes, but I just --
>> It's not part of the brain check. They do --
>> But we could make them up, you know --
>> Yes, it does go through, and it has a Likert scale -- we'll actually be talking about the brain check. We'll show you what aspects that that covers. But when we refer to our health history and some
of the questions that we ask -- I encourage you guys to go out and pull out your health history form that you guys use in your schools and say, are we getting there? Do we need to revisit this?
Because some of those is like, if a yes here, then what do we do? And we might want to develop more of a guided interview and some more questions along those lines, when we get to those different
layers of information. Yes?
>> What -- I have kids at opposite ends of the spectrum with my children, as a 20 month old and 17-year-old. The 17-year-old has been playing high school football, or he's the top [INAUDIBLE] for the
group. But he's also been playing football since he's been five years old. He's not quit. And I often worry about the concussions and things like that. Now dealing with the teenager aspect of it, do
you see where some boys maybe even more so don't want to admit to any type of head injury, is where I have a problem a lot with him, because he'll come home and he'll be throwing up, or he'll be
dizzy or he'll be, you know, and I'm, like, I know you got your bell rung. You know. But to them, it's so important to -- if this is on my medical history, what college is not going to want me?
>> Right. Yeah, should be jump into the concussion?
>> Let me stand on this side of you so that it goes into the microphone. So we're jumping into the concussion realm here, which --
>> -- which is part, it is a brain injury, right? So we have to admit that it is a brain injury. And the reason we don't talk about it on the upfront of this talk is because the world of concussion
can take us down a whole other realm, and we could come back for two days to do that training for you. But you bring up some good points, because it's on the continuum. So yes, we do see that all the
time where there is concern that for our football player, or for our kids that are doing athletic endeavors -- they have an injury, it is a brain injury. In theory, a concussion is going to resolve
fairly nicely in about three weeks or so. So we don't see it as a long-term significant injury, usually. We see it as a transient, short-term, and usually no lasting effects, right? But yes, so if
you have a situation where you have a kiddo with multiple concussions, or has a concussion where they're coming home and they are throwing up -- that is a sign of the concussion. And whether they
admit it or not, they should be out of play. So when we do our trainings for coaches on concussion, there are signs and there are symptoms. Symptoms are what they will report to you. Signs will be
what you see. And as the parent or as the teacher or as the educator that knows this kid well, if anything does not seem right to you by signs, you have the right to talk to the coach to get that kid
pulled from play, because it's our job as adults to be protecting the brain. So that kind of answers that.
The answer, the survey question earlier, the thing I like about it is it does force the parent to go in and say, the injury was at this age. How did it impact them with learning, behavior? It forces
them to tell you right off what they saw at the time, which kind of assesses the pre-post. And then that allows you to jump off into your other questions. So if they say there were no behavioral or
learning issues at that time, then you begin to make the case for -- we had a period of time where everything was okay, so I'm not leaning in that direction. If they're saying yes, I had some
behavioral or learning issues that I saw at four and a half, what did you do about them? Where did you take them? How did you pursue them? Which then again forces the parents to then either help you
figure out why it was that that was not looked at earlier. So it's a jumping-off point, either way.
>> So as far as some of the questions that we would look at for credible history, it's the where, the when, the how -- all of those details for each individual incident. So remember, we have to have a
reported incident. If it's more than one, we would want to do this process for every single one independently. So we have all of that data collection for each independent incident.
And then to also go through these, are these answers medically plausible? And this is a really good time to involve your nurse. If you've got access to your building nurse, make sure that they're part
of this, so that you can get some plausibility from that. If you're getting these reports that, you know -- my child fell out of a shopping cart, went into - was knocked out and had constant seizures
for three days, is that a plausible response? I'm not so sure any hospital would let a child seize for three days straight. They might have gone into a coma or an induced coma, right, to make sure
that the brain is resting. But -- so those are the kinds of things that you want to check out, you want to get details about. What does that look like, what did that mean? How long is a hospital
stay? What did the doctors say when they -- you know, blah blah blah, and you would have medical history on something like that if, in fact that was -- I'm not going to keep a child home at two years
old if they're seizing for three days. If there was no medical response and that was the details you were getting -- it's like wow, let's dig a little bit deeper. What does that mean, all right? So
and do we have any additional history of seizure activity, and all of those things. So that plausibility piece is also a part of this.
One very important thing to keep in mind is, be aware of your assumptions. You might have a child that shows up in your classroom with a physical scar, you know, halfway across his forehead, and you
can actually see where the stitches were. Is that a brain injury? We don't know. It may or may not be, right? It might just be a laceration that didn't affect the functioning of a brain. Could -- so
those are the things that stay away from the assumptions. Even with medical documentation, we might have some assumptions where we see scalp laceration. Probably bled profusely, and was very
traumatic, and all of those things, and lots of stitches, or whatever the case may be, is that a brain injury may or may not be. We have to do our homework. We have to put our detective hats on and
make sure that we're getting the details and the data that we need to be able to move ahead in that decision-making process, all right?
Also, so this is our Colorado kind of really general initial health assessment. It does ask some questions about brain injury, but again, I encourage you to go back and revisit yours and see what you
guys use in your schools and tweak if necessary.
So again, if, in fact, we go through this process of credible history and the team is, like, yep, we've got some data, we've got incidents, we've got some details around pre-post functioning levels,
we've got this, that and the other, and we want to corroborate our thinking, and we go to the brain check survey. So when we look at, in Colorado -- again, there's other surveys out there. There's
other ways that you guys can corroborate and other tools to use for that. We just choose this one, but there are others. And we recommend this because of the validity and the liability and the
specificity. So if you've got ADHD, specificity of this tool will weed that out around, no, this is really brain injury versus ADHD. And we have lost of our kids that have an ADHD diagnosis before
they get hit in the head, right? So things are happening. So that's why this one's a good tool, but again, we're corroborating with a parent voice in that data collection piece, by using the brain
So whether we've got medical documentation corroborated by a brain check, we've got that picture, or credible history corroborated by the brain check, are we there yet? We are not. That's one piece of
the puzzle by way of special education criteria. We must have educational impact, so we can have all of this data and say, yep, there's been incidents. There have been brain injuries and say yes and
agree to that. But unless we know educational impact, would we be able to qualify that student for special ed, right? So let's go there.
So when we talk about all these cautions, that's what we're saying is, we're not done yet. Credible history -- we're not done yet. We are still gathering a body of evidence in the impact piece. And
just a couple of cautions, obviously, and we talked a little bit about this earlier, that that gut feeling is there, and we all get those as educators. And we're pretty into with what's going on with
our students and our families, and we know a lot when it comes to that. But just a note of caution, don't go there without an incident. But it's also you have these kind of vague, or I've adopted my
child, and we don't really have a history. But I can assume that knowing -- I know the case of birth mother and birth father before I actually adopted this child, and here were some of the things
going on, so probably some abuse and neglect were going on -- don't go there. Yes, you have some issues, yes you have needs, but you do not have a reported incident. And that's what we went round and
round with when grandmother, who was legal guardian, and knew the birth mother quite well, but still there were no details around a specific incident. There was lots of sign -- lots of neglect and
lots of things that would happen, and boyfriends in and out of the picture and this, that and the other, lots of things to deal with, absolutely. But no incident. And she was absolutely convince and
trying tooth and nail to get to convince that school team that yes, there has been some traumatic brain injury happen in this, and perhaps that's the case. We just couldn't go there by way of this
particular special education category. We do our jobs, we do our assessments, we identify needs and we do what we need to by way of that student and meeting those needs. But we couldn't go here.
All right. How are we doing on time?
>> We're doing fine.
>> Good. Also, just as far as the -- it's not a benign label, obviously, you guys know this. There are some limitations and there are some outside entities that identify a brain injury as one of those
limiting or a barrier to other areas, so just a note as far as that goes. And it is about specially-designed instruction when we're talking about special education. You must have that educational
impact in order to move on.
>> Can I throw in a comment here about that? The reason we put that last slide in about there are some long-term effects, it's not a benign label, is primarily about this whole concern with
concussion. And a lot of our either parents or medical colleagues or athletic trainer kind of colleagues who know enough about our world to say kids with a concussion, I want them to have some
academic supports, so therefore, they must have - let's write a script for an IEP. Any of you receive a script for an IEP from a concussion? We are, as educators, really working very hard to try to
educate our parents and our medical professionals and our athletic colleagues that an IEP, special education, is a safeguard for long-term, permanent disability, usually requiring specialized
instruction, placement, programming and/or modification of curriculum -- that is huge. That is our biggest intervention for our kids, within theory, the mildest of brain injuries, which almost 95
percent of them resolve in three weeks with no long-term effects. This is not a good match. So but because certain groups believe that they know an IEP, we as educators have to be very, very helpful
to those groups to educate them that this is not a benign label. This is not done quickly, this is not done easily. And we should be very, very convinced that we have permanent and severe brain
damage meeting the level of support that you get with special education before we go down that road with concussion. We will do it if it seems like it is the absolute rare -- the rarest cases where
if you have a kid with a concussion and they need that level, but in my 10 years of doing work in concussion, I have only once gotten to that point with one kiddo. And hers was questionably a
concussion. She was on the back of a motorcycle with mom's boyfriend, the motorcycle crashed, nobody recalls anything that happened. He lost his leg. All of the energy was going towards his recovery,
that mom was just, like, couldn't handle all of it, and she ended up coming to use, the Center for Concussion, for her treatment. But I would really not say this was a concussion. This was a --
probably should have gone more to a rehab kind of setting. And after, you know, a number of months, actually years, of really then 504s, and physical therapies and all, we eventually ended up
staffing her, because that's the level that she needed. But that was not a concussion, typically. So that's why we put that in there, just to be absolutely sure. Are we switching out?
>> Is this you?
>> I think so.
>> I have a question.
>> So when you folks are gathering your credible history, is that part of the re-evaluation process? Or do you document, like so --
>> Re-evaluation for a triennial?
>> Or not a re-evaluation, as part of an initial evaluation?
>> Yes. For an initial evaluation.
>> Okay. So you already have had permission, you've already had permission signed, and --
>> Yes. Usually it will come to our attention, and probably yours as well, that either there is a report of an incident, right, and the parent will come in saying, I want my kids assessed for special
education, there is a report of an incident, either I have medical documentation, which of course is easier. So you start the process of medical documentation, your health history, your brain check
survey, and then what's the impact on learning? Or, I suspect my kiddo has had a brain injury. I understand there is a special education label for it, or the kid kind of mentions it to you, and
you're, like, hmm. And that is the incident. And then from there, the health history, the brain survey, the credible history interview, which Heather went over, which is huge, and then if you do
determine that, then what's the educational impact? Does that makes sense?
>> And so is it standardized? So, like, so the credible history at this point in time, what you're trying to determine is their disability, that's the first prong, right? That's what you're doing with
the credibility history?
>> You're determining is there an incident that's actually a brain injury, right?
>> Yes. Right.
>> Because you're determining the incidents. And then now, actually, this is right where we switch off, but the reasonable educational benefit piece of that educational impact is determining in
special education disability. So we have the --
>> So because it's a two-pronged -- okay. Because it's a two-pronged test.
>> And so the question that I have is, with regard to the educational -- the impact on educational programming. Do you use additional assessment pieces?
>> Yes. Yes. We'll actually go into that, which is next.
>> You guys are just, like, perfectly placed your questions to, like, take us to the next question. Yes! Excellent. So yes, so the credible history is, is this incident, is there enough evidence
>> Okay. So --
around this incident that it is probable and plausible that this incident on this time changed the trajectory of that kid's learning or development, to the point that you're going down special ed,
okay? That's one.
>> So that's prong one.
>> Yep. And then number two, even if it did, right -- so even if you did have medical documentation and/or credible history, but there was no educational impact, that -- then you wouldn't go down to
special education, right? So prong one, got that. But then you have to answer the question about reasonable educational impact, right?
So let's go on to that. And when we talk about that, that is, of course, prong two. It's required to be prong two in order to go forward with special education. And what we did with our TBI label was
to say, is there medical documentation and/or credible history, and is there evidence of -- is it evidenced in? And if you look at these, does this look familiar with you? Attention, memory,
processing, sensory, visual, motor, language -- it's the same thing. All in the same order again, right? From bottom to top. Keeps on going all the way up to the point where, if all of this, as
Heather said, worked in concert, you would have great adaptive skills and great academic skills. Generally, this is where our school districts start. He's struggling with math, he's struggling with
behavior, or struggling -- and then therefore, we're not here. But we know it's because we have to go and make sure everything is shored up in the more foundational levels. So our guidance followed
exactly that same pyramid that you guys have already learned.
So our evaluation, just like yours, IDEA, full and individual, sufficiently comprehensive to identify the needs, and that the assessment tools will then, of course, inform and directly assist in terms
of our interventions, right? We do talk about with our teams that the reason we do the assessment is, of course, to direct the interventions, which becomes with part -- we'll do that this afternoon
-- the questions that you're asking and that you're assessing need to be very well thought-out, or your interventions will not be very effective, okay? And I don't know if you still have that in
here, but when we do our trainings in Colorado, we have a slide in here that says, and in terms of assessments, you need to go back and be creative with what you have in your schools. We are not
making this presentation, and then every school psychologist runs back to their director and says, "CDE told me you must buy me a NEPSY, and then Heather gets phone calls. So we're trying not to do
All right, so any other questions on the process? And then we're going to walk through a case before lunch, to try to show you how this all really, as we said earlier, works well in theory but very
hard to implement in a case.
>> This is not a question, but would you repeat the [INAUDIBLE] and determination, because we do get doctor scripts, and people automatically think the doctor [INAUDIBLE] team. So could you just run
through what you said again, with the doctor's script? And you mentioned how sometimes it's not an automatic?
>> True. So yes, so --
>> For SDI.
>> Okay. So medical documentation, whether that be your actual reports from the hospital and/or a script from a doctor that says, "This child needs an IEP," the school is obligated to look at those,
consider it and then make a decision. And your decision as a school is based upon, now that I have this information, is there educational impact? And so you have a right as a school to come back and
say, "That is a lovely note, Dr. Smith, and we have considered it. But if you look at his entire history through up to high school, he has never had any learning issues or behavioral issues that has
risen to the level of educational impact, so therefore, thank you, but no thank you. We're not going to go forward with it. So you just have to have some kind of a process by which you consider it,
and your push-back is going to be on educational impact.
>> Yeah, that's second prong.
>> Does that make sense?
>> Remember we got the first prong, there's an actual incident, and we've got all the details around that. And a second prong and impact. We have to go there before qualification. And so that's the
educational environment and educational responsibility that takes it away from the doctor's hands, it really does. It's our responsibility to make sure that we are meeting those criteria, both prong
one and prong two.
>> Right. And that would be the same for any disability, right? We have a diagnosis of bipolar, good to know. Want to support this kiddo. But does that mean that they automatically get an IEP? No. It
depends on the educational impact. Some kiddos need it, some do not. So that would be the same. And that is the argument about concussion. A concussion is a brain injury. If they went to an emergency
room for a concussion, in theory, you have medical documentation. You would have medical documentation on thousands of kids in your school district. Does that mean they need an IEP? Likely not,
because of the nature of what a concussion is, and because of the severity, or the intensity of supports for an IEP would likely not match with a concussion. So that's what you're juggling there.
Okay? Good questions.
Okay. Shall we walk through a study? OK. I'm going to introduced you to Ethan. Ethan is a 10th grader, 15-year-old, who is with mom and stepdad and an 18-year-old sister. Parents -- I actually ended
up receiving Ethan when I was in the concussion clinic. So this is -- I had the hat on of being in the concussion clinic, saw this kiddo for a concussion, and his mom comes in and basically says that
she has really always worried about Ethan, had real concerns. And she was also -- besides wanting to have him treated for his concussion, she was working with the school on getting a special
education evaluation done, potentially for traumatic brain injury. And when I talked to the school about that, which I do with every single kid I see with a concussion, I am in touch with the school
every single time I visit with the kiddo. I talked with someone at the school, and they had actually said yes, the fall of his sophomore year, we have had concerns about Ethan. We have been following
him. We have basically doing some RTI-ish-ness, not for special education, but RTI philosophy supporting this kid though his freshman year, and we think it's time to move forward with an evaluation.
So there was corroboration that the school also had some concerns.
Then mom was concerned that something was wrong, and the school was also saying something's not right, so that's that gut you guys are feeling, you know, with some of your kids. He had already had a
full evaluation done in fourth grade, and that was because -- that was before it was on anyone's radar about traumatic brain injury, so that was under ADHD and learning disabilities, because he had a
lot of those kinds of issues. Attentional issues and learning issues.
So he had a history and a diagnosis of ADHD already. He was diagnosed in second grade with that. Mom had tried some medication, but had not found those to be very effective. They would either make him
super over-hyper, or didn't really impact him. He was also prone to headaches, migraine headaches in the family. Biological dad was questionably bipolar, but that was mom's diagnosis of biological
dad, that was not a confirmed diagnosis that we had, right?
So this is what -- this is what I got from the school. Reading and writing and math concerns, some memory and attentional issues, poor work completion and some emerging defiance and work refusal. That
was fairly new, coming into his sophomore year. That hadn't been a big problem earlier on. And in the past they had worked with him on reading and writing and general education, kind of like the
interventionist model. And they had given him, as he was gone in high school, they had the study hall, so they're sort of starting to give him a little extra support. These were his current grades at
the time that we were seeing him, so you can see that they're all pretty low, he is really struggling. English is a problem, history is a problem, okay?
So in this situation, is it worth us going back through and trying to do an evaluation for LD or ADHD? Would that be where your team goes? It's possible. We've already done that in fourth grade. But
now mom has a real question about traumatic brain injury. OK, so let's look at -- do we have medical documentation, or are we going with credible history for traumatic brain injury?
Here's his history. When he was seven months old, he fell out of mom's arms, fell on the concrete and scuffed the back of his head. Okay, so remember, again, going back to what we talked about with
the report from parents on early trauma or early brain injury -- in this case, this was a mom who had an explanation, this was an accident, right? But sometimes that's not always the case with your
families, right, where they're not going to report to you that there was a shake or a situation where they hit the kid. But that was not the case here. Then he hit his forehead on the glass table,
four to five stitches to his forehead, he did have a gash here when he was about three. That's that early active kid that Heather was talking about. Then when he was on a visit with his dad and
sister when he was seven, dad and sister were fighting, he tried to intervene, be the big man, and dad took him and pushed his head into the windshield, cracked the windshield, okay, and then he was
there for about another week or so with dad before coming home. Skateboarding accident where he fell off, he blacked out, but that was not diagnosed a concussion. Anybody see anything wrong with
>> Yeah. By definition, if you black out, that is a concussion. But it was not diagnosed a concussion, so no medical records of that. Snowboarding accident -- hit a patch of ice, hit a tree, but he
just reported that to mom again, he was not seen anywhere for that. And then he had a bicycle accident right after that. He fell off, and that -- came to the emergency room, and we have a kind of a
partnership with this emergency room that he ended up getting referred to my clinic, okay? So this is -- I'm seeing him for this concussion. But this one concussion, in theory, again -- does that
explain what's been going on with Ethan for all these years? No.
So we're treating him for this concussion, but then I thought, well, this is a great case to also sort of work with the school, help them figure out if there is -- is this medical documentation and/or
credible history? This was actually before -- this was in the process of piloting this for the Department of Education, so was walking through it with the kiddo. Okay.
So given this background, then, we have kind of these guiding questions, and we have some of these if you want a copy of them, but what are we really looking for? How do we need to assess this? So
with Ethan, what we're looking -- our concerns are academic, some emerging behavior problems, right, and our question at this point for an initial evaluation is, is there medical documentation and/or
credible history for traumatic brain injury? Or are we going to look at LD, SED -- you know, that's our behavior -- or any other category? And what other things might we, of course, want to be
looking at for a 15-year-old? We want to look at vocational, college-bound, all those other things.
So where do we need to put our -- where do we need to be gathering information? So we need to do a very thorough developmental history. We need to look at that medical documentation, if we have some,
and/or credible history, if our medical documentation isn't really any good. And then in terms of educational impact -- the academics, the behavior, the attention, the vocational.
So in terms of looking at Ethan, we did the developmental history, which -- we do have that in here, right? Yes. So this is mom's developmental history. There were really no concerns with this kiddo
early on, had tubes put in for some ear infections. We do have a section in our little developmental screen, and this is where Heather says go back and look at yours to see if you want to do
something more in-depth than what we have. But, you know, did he ever have a head injury, or concussion? And she reports that he had had some loss of consciousness for a few minutes, so, you know,
what is that kind of -- what is the red flag for you guys to start to pick up on some of this? So this is her report of that. And then we also had her do the brain check survey, which here, blow to
the head, at seven months, one year, seven years, and at thirteen and a half concussion and loss of consciousness, those are the things that she had reported to me already. And then, we delved down
deeper in terms of, what did you see immediately with each one of those? Primarily, we're really looking at that incident with dad, the current concussion, and you can see that focusing and attention
was really a problem, coping with changes and transitions, maintaining relationships was a problem. Down here, monitoring his own progress, assignments -- so it was affecting him with learning and
behavior, it was affecting him with attention up here. So you see how that we sort of -- you sort of force parents to kind of really think through how this is impacting.
Okay, so that's how we use those two screens to actually use them as a jumping-off point. Medical documentation -- we only had medical documentation from the time that he was -- this current
concussion, right? We didn't have anything from the time he fell. We didn't have anything from the time he hit the tree skiing. We didn't have any medical documentation from that incident with dad.
So going to the emergency room for falling off of your bike for a concussion that I'm treating right now, is that enough medical documentation to really explain the years of concern, of attention and
learning, all the way through? No. So we really don't have medical documentation.
Credible history -- so that pushed us into the credible history side, okay? Credible history has a burden of proof that is pretty high, right? So corroborated incidents of one or numerous, and that's
corroborated by credible reporters, so parents, or how are we going to get that information. So we're beginning to kind of corroborate it with the parent reporting it on the health check, on the
survey check, right? And then what we ended up doing, because we believe that credible history requires a sit-down interview, maybe one or two or three if you're really going to go down this road --
what we did is, we have as many people interview mom or parents as possible. So you want mom, dad, grandparent, caretaker if possible. You want social worker, psychologist, nurse on the other end, so
you are trying to get the same stories, okay? In this case, we only had mom to be able to sit down and ask these questions. But going through in detail, what was he like after each one of these
incidents? There was really no big developmental changes or behavioral changes from the seven month old one, or from when he was three. He was just an active kid before, active after, but learning
was okay, was in preschool -- no concerns there. We didn't have dad to ask any of that to, right? The situation with the -- so we had mom talk to the social worker and the nurse, and kind of be
collecting all of this different information in various ways.
The situation with the seven-year-old, when he was with his dad -- that really became the biggest concern, right? That seems to perhaps have been where maybe things went off track. When we interviewed
mom, she reported that after he came home from that visit, he was not the same. He came home very -- he had lots more headaches after that point. He was a much more moody kid after that point. He was
behaviorally a little bit more, you know, hyper -- but he's also coming home from a visit with dad, right, sometimes that happens over the summer when you have this co-parenting situation. When did
he get the diagnosis of ADHD?
>> Second grade.
>> At second grade. Roughly right after that. So he came back. He had some concerns, and the second grade teacher was, like, "This kid is very hyper, I think he's got ADHD." So what did mom do? She
took him in, he got the diagnosis of ADHD. He was an active kid before, but he was way worse afterwards, okay, so that's a hint, okay?
So that's where we really began to think that that might be, is this possible and plausible that this injury at the age of seven is really the traumatic brain injury that spun the rest of this off?
And then you've got -- so you got the diagnosis at age seven. The way that we really were able to kind of figure this out, who else is perhaps someone who is a reporter here that we could get some
>> Sister. Sister was a senior at this school. So we had the sister come in, and we talked with the social worker and the nurse, and we were able to get the story that this, indeed, happened, that
after this happened, they had a whole other week there with dad, and he was very impacted by this. He slept a whole lot more, he had headaches at the time, he was very moody after this, and she
corroborated that this kiddo was really not the same from that point forward. So we're beginning to build a really good case of credible history on a kiddo who is already very active, on a kiddo who
had some other issues before, and some other ones afterwards. But this is the one that I think that we are -- again, if we're going to go to court on, do I have enough data to support this, all
So we've built a very good case that this was the situation. And I think it's when we do the assessment piece, but -- and I will show you the data. He had already been assessed at the age of -- in
fourth grade, for learning issues and attentional issues. On his learning assessment data, what do you think that showed? If you were going to predict learning for a fourth grader for Ethan, do you
have any ideas what you might find if you were testing him in fourth grade?
>> Considering the seven -- the injury of --
>> No, not considering TBI, but looking at learning disability.
>> It would probably had lower scores when looking in there, and then his processing speed, and then -- but not necessarily those in the area of language, and [INAUDIBLE] how the impact was.
>> Yeah. If you're learning disability, you're going to look at cognitive.
>> This was a little bit further back, right? So this was the aptitude achievement discrepancy?
>> Cognitive was here, achievement was here. So when they were looking at him for special education in fourth grade under the lens of learning disability, he didn't qualify because there wasn't a
discrepancy. But that's not what the issue was. The issue was traumatic brain injury. If you look at his testing, which we'll show you -- I don't know if we have time now, or if we just keep on going
or we go to lunch -- how are we doing with time -- you will see unevenness throughout his testing, which is the hallmark of brain injury. But learning disability didn't answer it, so he didn't
qualify. Attention deficit -- a lot of kids had that, he didn't have enough for it to be his label. Do you want me to keep going on?
>> There's a general assessment info first.
>> Yeah. So should I just -- time-wise, do you want me to keep on going? Okay. So that's kind of the -- so in the end, what we ended up deciding with Ethan was that we had enough information for
credible history for the one incident, not for all the others. Of course, multiple head injuries after that are not going to help his situation, but we had that, and therefore, the rest of our
assessment really then shows in the assessment that we're really looking for traumatic brain injury, not learning disability. And he didn't really have ADHD, he had attentional issues secondary to
the brain injury. That make sense? Okay.
So that's how in-depth you have to go. And that's how corroborating you have to go with your -- either your interviewers or your interviewees, and the more you can get the same story and really make
this make sense, the better you're going to feel as a team, as well as you're going to go forward in terms of justifying it.
So when you look at assessment from the lens of brain injury, it's going to slightly shift what you're looking at now, right? We're not going to just run out and grab our [INAUDIBLE 02:04:36] kit,
grab our Woodcock- Johnson kit and just do the same things we would do for learning disabilities, we're going to really start to delve down. So keeping in mind that there are many different levels we
can assess on, the first place that we always start, and this is also on the CoKids Website, it's in the brain injury manual, and feel free to use this if you want to. There's a five-page teacher
input functional observation form made up by some school psychologist who worked with brain injury in the State of Colorado, who helped advise us. And what they have done is, again, they have taken
all of these different domains that we talked about, with the most important ones first, and broken it down to, what will you see behaviorally? So the first thing you might do, once you've decided,
you have medical documentation and/or credible history, is you're going to sit down with your problem-solving team, or your sit team, or whatever you call it here in your various districts, and the
teachers, and you're going to now get input from the teachers on how is it impacting them educationally? This is your going into prong two, right?
And so, as you're sitting down with your teachers -- I mean, for Ethan, does he -- where does he rate in terms of focusing on the teacher lecture? And so there are two pages of this to kind of give
you an example, but this is really a five-page form. And again, it will directly walk you from the bottom of your pyramid up, in the behavioral and learning manifestations of each one of those
domains, so that your teacher can say, "Oh yes, Ethan has trouble paying attention." She doesn't say, "I think he has a skill deficit in attention," which is the bottom level of the pyramid. She'll
just tell you what she sees behaviorally.
>> At what age would you say that is appropriate [INAUDIBLE]?
>> To use this form on? I'd say all ages.
>> Yeah. We've used it, I think, all the way, elementary through high school. And you might need to adapt it a little bit; if you are, like, with your BrainSTEPS team, and you're sitting down with
your teachers, you can -- you can kind of -- if the language isn't quite right, because I can't say we've fit it for all levels, but you can adapt it.
>> For kids in secondary, would you have each of their teachers complete one of these?
>> You could.
>> Or do you sit down with all of them together, have a conversation and do an average of what they are?
>> Yeah, I think it would depend on the situation, and the relationship that you have with teachers. I also have used this as a teaching tool for teachers, because when we learn about domains, we're
talking about attention and processing speed and memory and all of those things, and we kind of get what that looks like. Teachers may not adapt that classroom behavior, what they see in the
classroom with memory. What they see in the classroom with attention maybe, because they probably see a lot of attention issues. But processing speed? Perhaps not. So it could also be used as a
teaching tool to say, what kinds of behaviors or things do you see in the classroom? And then it might lead you to, oh, we're talking those fundamental, or we're talking intermediate and some
language things going on, or whatever the case may be, because they see it in teacher ease, right? They have a different perspective of how that behavior or how that domain is showing up in the
classroom setting. So I think you can kind of come at and use this tool in a lot of different ways to get the right data to at least start the assessment process, or prioritize which areas you're
going to be looking at first.
>> Is there something out there younger than school age? I work for -- to three. And kids that are in car accidents, or something like that, or fall and hit their head, or are in an abusive situation
and we're working with children and youth, or something like that.
>> What about chapter two?
>> Sure. We talked about chapter two, do you know of any assessments specifically for that?
>> I don't.
>> I could take a look at this, because I think some of these areas could be adapted pretty quickly.
>> I don't know.
>> Yeah. There's no assessment tool like this that we're aware of. I think the hard thing for little ones, for little ones is, there's so much natural development that's still happening, and you
wouldn't expect that their attention be very good pre-injury versus post-injury, because it's just developing. So I think that requires your guys really helping your teams and your parents to drill
down to even baseline to their attention, did they have pretty good emotion regulation, and now afterwards don't? Were they able to put themselves to sleep before, and now don't? I mean, only I what
is already acceptable for little guys to be able to do, chapter two of the brain injury manual that Heather showed you is dedicated to normal development. But it's broken up from the lens also of
brain injury. So it was written by Jeanne Dise-Lewis who was a colleague of ours, unfortunately passed away last year, and what she did is, she said, here's typical development, and here's if a brain
injury happens at the age of two, here's how it might impact typical development, and how it might look. So that might kind of give you some ideas to jump off from. But I would say those little guys
are tricky, just because you don't have that benefit of the pre-post, the way you do with some of the older kids.
>> And you may have to look at the physical pieces -- I'm just standing next to Karen because I like her a lot -- (laughter) and the physical pieces like the sleeping habits, eating habits, lethargy,
emotional regulation -- all of those kinds of things are really queuing into when you've got a little person, of what's going on. And that pre-post picture.
>> It's hard for us, too, because maybe there was an incident that occurred, and you don't -- it's hard for parents and maybe some of us to see, like, well, is this just a developmental thing?
>> Or is this happening? And how do we get, you know, early intervention involved when they don't quite qualify, but you have that feeling where -
>> -- this kid might need some help now to get all of this --
>> Exactly. Yeah.
>> -- in his brain, you know, getting all the connections and doing the best that needs to be done.
>> Or maybe he's not quite [INAUDIBLE] yet.
>> Yeah, right.
>> Another really important aspect of that is documentation. So we may not have that full body of evidence, but what do we do? We document and document and document on our thinking and what we're
seeing, and so that it stays in that historical record, because next year, if it's gone, we're starting over anew. And that's what I find a lot with re-evals. Every three years we did a great job of
documenting everything, and it goes away for the next two years, and we don't even go back and revisit it. It's really important that that historical documentation follows, so we really can use that
as a foundation of why we're doing what we're doing. And if we need to add interventions, we have the documentation to support that.
>> Yeah, so many of the things that work well for kids that are just a little bit struggling developmentally work well if that is coming from a brain injury, or other neurologically-impaired things.
So the beauty of working with the little guys is just go ahead and do the early interventions under whatever you can, constantly keeping in the back of your mind, constantly documenting, because it
may become a bigger issue down the road. But for now, go ahead and give them -- because the strategies work well for all. Okay?
Just one other point -- there is no scoring system to this, so it isn't like you can add it up and kind of, you know, like compare it against the norms. It's never been taken to that level. But you
can visually see, all of my issues are really in the area of memory, or all of my issues are really over here, or that. So you kind of use it -- and so if you want all your teachers to do it, that's
fine, if you want to do it together as a group. But really help them to be thinking along the lines of how does this manifest in your classroom, and I'll figure out which domain it comes from based
upon what you've learned here, because then you're going to take that and figure out how you're going to then find a test to really look at that, if you're doing assessments. And then you're going to
find an intervention that really fits with that, because you've drilled it all the way down, all right?
So start with this, okay? And keep in mind that there are a lot of pre-existing conditions; when you're picking up and you're starting to do this, you're picking up a lot of things, right? Kids with
pre-existing ADHD for some of our kids, there's a higher risk of them having brain injury because they tend to swing from the chandeliers, and that's how they get their injuries, or just in general,
some interesting neurological kinds of processes anyways, for some of our kids, right? And that -- keeping in mind that many of our kids, if we don't look at them from the lens of TBI, we start to go
down this other road. We start to build a body of evidence of that they have a different label, because you can support that with -- I mean, we're talking about objective data, here. So a lot of our
kids with traumatic brain injury have gone down the road if SED, or emotional disability. And therefore, many of our kids are not either getting the right accommodations for their label, or any at
all. So that's the research on that.
This is a nice little chart that comes out of the Oregon group that shows you -- I mean, here are the different characteristics that many of our kids have with these different labels. But these are
the ones that are very specific to traumatic brain injury, so this sudden onset, because you have an incident, okay, it's not just it pops up because conveniently so, but you have an incident where
that changed things. The pre and the post -- for many of our kids it changes their sense of who they are. So that, then, spins off into some anxiety and depression, which you don't want to just be
picking up that, but in the context of the brain injury. You often, if it truly is a brain injury, you often have some other medical complications. And the biggest one for that is fatigue. I mean -
and if you talk with adults who have had brain injury, fatigue is one of those things that ends up almost being a lifelong problem. I mean, they just have to re-regulate how they go about business,
even in their work settings years later. And they go to bed earlier, they're very aware of that. So that's a very common one specific to TBI. And longer-term memory tends to stick, but new memory,
short-term memory and all of that, which is of course what school is all about, is the biggest problem. So you sometimes see that specific to traumatic brain injury. Question?
>> I think in looking at the different labels, it makes sense to say TBI is the primary disorder, but then which also shows up as LD, or as emotional disturbance.
>> Yes. If you really can make a case that TBI is the primary, it is a perfect way to look at it, because then a lot of the things, the interventions and assessments you do for LD or behavior are
going to be very helpful to that, yes. And if you can't actually pin down the TBI, you're just going to go ahead with the others, because those are still going to be helpful. Yes. And it becomes
really kind of an issue, sometimes, with, like, manifestations when -- so you couldn't with TBI. You went with LD, and now this kiddo has a behavior, brings a knife to school, but is under the LD
label -- that's when that's not going to make a lot of sense -- yeah. But you did what you could. I mean, if you can get it, definitely go with it.
>> Do you have instances in your state where the TBI is the secondary disability? Because I just saw that happen with a student that I was working with, and I'm just not understanding after listening
to you why that would even happen.
>> And it's not under multiple, so it's not the cognition piece? Yeah, I would be that questioning as well.
>> My student falls under the disability category label with a TBI, and that's secondary.
>> I think one thing that really complicates the issue is the word brain injury exists under SLD. When you read the definition of SLD, brain injury is there. And when we talk acquired brain injury in
the non-traumatic form, perhaps you would want to go that route. Perhaps you'd want to look at "other health impaired." I always say "other health impaired" makes a lot more sense because we can make
it be whatever and how broad, and make it all of those -- go through all of these domain areas, do our due diligence by way of assessment, and document everything. It's the through the lens of brain
>> Yeah, oh. Yeah. Well --
>> This is a concussion [INAUDIBLE].
>> I think the SLD definition by itself confuses people because it's there. But I always, always -- and you want the best thing to fit. And if you're using the lens of brain injury to understand why
everything else is happening, that's the best case scenario, because you're going to take into consideration unevenness and attention and memory and all of those things that are typical with brain
injury, where if I'm only looking through the SLD lens I'm driving myself nuts, because they're not responding like every other kid that's under the SLD category appropriately. It's just not
happening the same way. So I'm going crazy over here.
>> You've got to wonder if that concussion thing is some other need to document something for some reason.
>> [INAUDIBLE] for testing.
>> Not enough.
>> Yeah, exactly. So we have about eleven minutes before lunch. Do you want me to show you the assessment? Finish on Ethan's assessment data and go off to lunch? Okay. So I'm going to zip through very
quickly kind of the assessments because you will get a copy of the matrix -- is that right?
>> Yeah. We've got only about 10 copies that they can use.
>> Okay. But you can go to CoKids. So on the CoKids Website, we have created a matrix that said, here are your different domains, and if you drill it down to -- I think there -- I need to look at
attention. What assessment tools would you use to specifically look at attention versus memory versus all these different ones? And you've got your functional observation form coming from your
teacher, saying, "I don't need to look at this over here, speech, language is not an issue. I need to look at attention and memory, what would I use? We picked specific tests that go with each one of
those domains that are parts of tests that specifically look at those areas and domains, and are things that can be used in schools. These are not things that neuropsychologists can give, only
neuropsychologists can give; this is something that you guys in your school in your different disciplines can give. And we would suggest you give them as a multi-disciplinary team. So your speech
language persons may be doing some of it, if it falls under their category and psych, and you're creating a body of evidence. So because when you look at what's out there, there is isn't much out
there specifically for traumatic brain injury in terms of assessments and interventions.
So we want you to think outside the box here, okay? Think of your assessments in a way you have never thought of them before.
>> Whoa, that's not good.
>> Oh, I don't need this. I'm already late.
>> Somebody will come. Anybody out there?
>> Do you have a phone?
>> No. Sorry. Somebody? Hello? There are two people stuck on an escalator, and we need help. Now, would somebody please do something?
>> I don't believe this. You've got to be kidding me!
>> I'm going to cry.
>> Well, there's nothing left to do, is there?
>> Hello! Hey, don't worry about it, I'll fix it in a second.
>> He said he can fix it! All right! All right, that's more like it. He says he can fix it.
>> All right. All right, we're going to zip through this real quick. Here's the CoKids Website, right? All right. If you go to the matrix right there, it's going to break it down by these different
domains. And then if you click on each one of those domains, it's going to take you to here are some suggested assessments that school people can do. And again, off your functional observation,
right? So you brought it down to attention? Here are some that you're -- that have some specific things that you can look at for attention, for memory. Now, we have to update this. I have to admit,
as soon as we put it out, it's out of date. So bear with us, we are in the process of updating it on the Website.
So again, going from the bottom up, and I'm just going really quickly with these because I want to show you Ethan's data -- these are all things you do, right? All right.
>> And remember, we will deny it if you go back to your district and say, "Karen and Heather from Colorado say you must buy this assessment."
>> They'll call Brenda up. All right, so we want to go further, right, with Ethan. We're going to go with credible history. We need to see if there's educational impact. So our questions, formal,
informal testing, what do we need to do? So we go to the matrix to start to try to figure it out, and here's kind of what we came up with. School psychologist does some, you know, speech and language
was never a concern with him. So we did not do specific speech and language testing. You guys can decide that. On an initial, you might want to. Definitely on triennials, you might not. And of course
we are going with credible history here, so, okay -- so look at his -- this is his functional observation form. You can see that in terms of memory, we've got below average. In terms of short-term
memory, working memory, long-term memory, processing speed below average. Cognitive fatigue, which is very characteristic of kind of the brain injury concerns. So executive functioning almost across
the board kind of in the below-average range. But in terms of gross motor, average. Visual, spatial, perceptual in terms of doing fine motor and some puzzles and things like that, all fine. So this
helps me to drill down where I want to go.
So we did do a basic cognitive test for him. Do you see how these scores here, when you compare them, if you are looking at your discrepancy model in fourth grade, you can see why he didn't qualify,
because overall, there's not huge ups and downs with this, and it's not discrepant from this. But when you start to look at these scores, you begin to see that there are areas of fluency that are a
concern for him, so -- but this still doesn't give you the whole picture.
So we started looking at the NEPSY and we started looking at things like poor inhibition, things like immediate recall was fine, but delayed recall would decline with time. Memory was only okay if you
paired it with meaningful information, not if it was stand-alone information -- that kind of thing. Poor visual, facial recognition. We did the BASC, you can see that these right here are the areas
of concern. The teacher has a concern with conduct; a lot of that behavior was coming out, but my assessment of that was that the academics were getting way too hard. I mean, you look at his
cognitive scores, you look at his achievement scores -- he is now struggling, the farther we go up in terms of his high school career. And so you can see that the teachers have picked up on the
attention, they picked up on the behavior. And he is, at this point, really his self-esteem is going down. And in terms with what mom had reported on the brief, his ability to inhibit was
significantly impaired, his working memory, his planning was impaired. So how did this help us figure out, when we ended up finally putting it altogether, his main concern -- my assessment was that
he was really, at this point, remember that kind of cliff of executive functioning? Well, there's also a cliff, right, of academics. It was getting too hard for him, he was not getting enough
support, and we were not supporting him academically, and therefore, secondarily we were having -- and he had pre-attentional issues which were now really exacerbated. So attention was really a
problem, and behavior was really a problem. He was under the TBI label, but this was how it was primarily manifesting, and in my opinion, how we had to go in terms -- the order of how we had to
So we ended up giving him some support from a learning specialist, for the academics to try to help that not be quite so frustrating, which we would then decrease some of the behavioral issues, and
beginning to really work with him on some vocational things. He really wanted to be a firefighter, and he ended up kind of doing an apprenticeship with the local fire department close to his home.
And that really helped to turn around the self-esteem, and everything else that also was going on with him. We had to talk to mom about the attentional issues; those were a problem before and really
a problem now still, whether they wanted to medicate those or not, but if you did want to medicate those, go back to the doctor and talk to the doctor in the context of traumatic brain injury might
change how they would medicate those, and/or there are strategies for that. Stop, relax and think, some cognitive behavioral things. And this is a kiddo who, if we can get him to have some insight
into where this is coming from, we could maybe teach him some strategies.
And so we talked about that at school and at home. In terms of his label, on paper -- I don't know if you guys here in your state have -- once you staff a kid in with a traumatic brain injury, they
get a traumatic brain injury specialist that follows him, right? No. (Laughter) Brenda comes to your school and follows every one of your kids, right? No. We don't have that in Colorado, either. So
this is a part of the problem with traumatic brain injury, right? If you go with that label, there is not a classroom to put them in, there is not a case manager that automatically takes that
responsibility. So that also becomes an issue with your assessment and your ongoing intervention planning, right?
So with his case, we ended up going with credible history for traumatic brain injury, but who really then had to be the one that writes up the IEP and ends up following this on paper? Ended up being
more the LD teacher, because the primary issue, I really felt we needed to bring down the academics so he was not so frustrate.
But in practice, these kids belonged to everyone. We had to have the psychologist working with him, the social worker working with him, the nurse working with him on his fatigue. We had to get some
vocational supports in place for him outside, otherwise this is not really just an LD issue.