HRSA/MCHB 2005 FEDERAL/STATE PARTNERSHIP MEETING

PUBLIC HEALTH ACROSS THE LIFESPAN

Identifying and Serving Children with TBI

JANET TYLER: I thought we would start out by talking about some of the basics, and I know this is going to be a review for some of you, but we weren't sure exactly how much background you all had in traumatic brain injury, so just a few minutes of the basics.

When we're talking about traumatic brain injury, we're talking about basically open or closed brain injuries. An open head injury would be when something actually penetrates the skill skull, so most commonly you would think of say a gunshot wound to the head.

I know through our projects in Kansas we have seen numerous kids with gunshot wounds to the head. Our youngest was 18 months old. She had been accidentally shot by her 3 year old brother. We have had a lot of high school students that were a result of gang‑related type violence. We have a lot of hunting accidents, so those types of things.

In addition to say bullets through the skull we also had seen kids who have had other kinds of penetrating injuries. For example, we had a young man that was playing at a construction site and fell and had a piece of rebar through his skull.

The closed head injury is where the skull remains in tact, you might have a fracturing of the skull but you still have the enclosed skull and the damage takes place within that enclosed skull.

What exactly does happen, if you think about the brain as resting and fluid inside the closed skull, you start having some pretty trauma movements say in an automobile accident where your head slams against the front shield of the windshield and so you have this violent movement of the brain slamming forward in the skull.

As the acceleration stops, you get that rebound action. So this slide represents potentially areas that could be damaged during a front head injury. You know, you might have your head slamming forward, backwards, it might bounce up, it might have twisting and rotating, so that's why it's so difficult to say this child had a right front head injury, therefore these skills are going to be affected because we don't know all the different areas.

And this shows exactly what does happen during that kind of coo contra coo kind of injury. You can see also that there's a lot of diffuse damage going on, not just bruising.

We know that our brains are made up of billions and billions of these neurons, all nicely interconnected. They communicate with each other through chemical impulses. But when you start having this violent movement of the brain, and your brain is made up of different densities of tissue, you start having these nice neurons that were all nice and connected they start coming apart, so you have this shearing action taking place.

So you have some of those neurons just stretching, breaking off, some of them might die at the point of impact, others are going to later on atrophy and ball up.

So whereas once you had this nice normal neuron connection, you now have an area that is actually damage to the brain. Those neurons are gone. That's permanent damage that occurs to the brain.

We do know that some spontaneous recovery takes place, but we're really talking about the brain reorganizing itself versus actually growing and repairing the damaged areas.

We also know that besides the initial bruising and swelling of the brain that takes place, we also have ‑‑ could have potentially bleeding that takes place within the brain. This could be from the bruises that occur, this could be from that shearing that we talked about, and so you have it where that they might actually have to go in and surgically stop that bleeding from taking place.

They might just be watching to see if actually the bleeding is going to get any worse and then so that they might later have to go in, so then you have further damage that's taking place. So you have the initial bruising, tearing, swelling, all that that goes into actually having an impact on the brain injury.

Now, we can medically define traumatic brain injury, and they do so by looking at mild brain injuries. Mild brain injuries is where you have a brief or no loss of consciousness, but that you would have some of the signs of concussion showing up. So it might be vomiting, you might be tired, you might have a lack of recall of the injury itself.

Now, those are all kind of classic signs. Now, one of those, for example the vomiting, what they have found out that persons who are more likely to vomit after a mild brain injury or concussion are those individuals that are prone to motion sickness.

However, people generally equate that with severity of injury that, oh, my gosh that's a sign, that means that the brain injury is so much worse. Actually it just has to do whether you are prone to motion sickness, but it does tend to get a lot more reaction when you go to the hospital. But those are just some of the signs. So that would be concussion or mild brain injury, and that's the most frequent type of injury that occurs.

The moderate is where an individual is in a coma for less than 24 hours. Now, they talk about you being unconscious for like up to an hour, and after that they talk about you being in a coma. Now, with a moderate injury you would actually, if they did CAT scans, MRIs, you could probably see areas of damage. There might be some bleeding, there might be some bruising that you see.

With the concussion or the mild brain injury if they did a CAT scan, you wouldn't see any actual damage because it's more at the diffuse level.

And then severe is anything where the child is in a coma for more than 24 hours.

Important to remember that to have a concussion or a mild brain injury you don't have to lose consciousness. For years we kind of had that definition saying well, he wasn't knocked out, so that means he doesn't really have a brain injury.

Now, with all the research that has been done recently in the area of sports and concussion, there has been a tremendous amount of research, and they are really watching those high school and college level professional football players and in different sports and getting a lot of good data of that.

Certainly we do know that there does not have to be a lack of consciousness to have ‑‑ be considered having a traumatic brain injury. Even those people that might have been a little bit confused after the injury that they sometimes have the symptoms of post concussion syndrome.

Now, in the schools, we do know that brain injuries can range from mild to severe. We know that from the research that has been done that even mild brain injuries can sometimes have an impact on the students' educational performance.

Generally mild brain injuries, the symptoms will resolve within a few days, a few weeks. Most of them are resolved by three months. We do have some reports that kids with mild brain injuries or concussion have more long‑term problems. But generally those are short‑term impacts.

Moderate, we certainly know that those kids can have physical cognitive behavioral.

And then with severe, it's almost always that those kids do have those problems and that they generally last throughout the child's lifetime.

Now, educationally we define traumatic brain injury a little bit differently. Remember we talked about medical definition, now educational definition. This is to qualify for special education services within the school.

They have it kind of simplified. It's an insult to the brain. It's got to be from an external physical force. So originally when they talked about doing the definition, they talked about including things like strokes and brain tumors, and certainly those kids have a lot of times very much the same issues of

sudden onset, ongoing medical needs that hospital to school transition need, but in this case to qualify under the category of traumatic brain injury, you have to have an opened or a closed brain injury. It can't be of a degenerative or congenital nature, it can't happen during the birth process. We know a lot of kids have stroke or lack of oxygen during the birth process, they said no, it has to be where the child has some period of normal development and then has this event.

And then the event does have to cause some kind of impact on the child's performance in school. It can impact all different areas or the student can qualify even just under one of the areas, if it's under speech or language problems, they can qualify if they are just having behavioral issues associated with the traumatic brain injury.

We do know that brain injury is the leading cause of death and disability in young children and adults. That surprises a lot of people because you do hear a lot more press it seems like of kids who have had spinal cord injuries or some of the other disabilities, but certainly it is the leading cause of death and disability in our kids.

According to the Center For Disease Control, these statistics just came out this year, that approximately 1.4 million individuals, and that's all age levels they are talking about, receive a TBI, but then I have got it broken down into the age levels for the students that we serve.

Zero to 4 years you can see it's pretty high incidence, one out of 90. The 5 to 9 years and 10 to 14 they break down just about roughly the same, about 159 kids experience the TBI. And then you can see it jumps up a little bit again with that age, 15 to 19 group, and that's certainly where we see all those automobile crashes coming into account.

Now, we do know that approximately 80 percent of these injuries are seen in the emergency room or emergency departments. About 70 percent of these kids are hospitalized. And then we see about four percent of those resulting in death.

The ‑‑ for the school age population, now, the center for disease control, when you are looking at the whole population from birth to death their figures statistics are a little bit different. The number one cause that they have found for if you are looking across the entire lifespan is false but when we are talking about our population of school age children, motor vehicle crashes is still the number one cause.

Certainly for our younger kids we have a lot of abuse coming into play, falls, droppings at that age. When you start getting into the adolescent group, we have of course huge incidents of motor vehicle crashes but then we also have sports injuries coming into play, assault and other things.

ANN GLANG: One of the biggest challenges in serving kids with brain injuries ‑‑ is this working now still? It went off. One of the biggest challenges is keeping track of these kids when they go back to school with the way hospitalizations are now, medical reimbursements are now, kids just don't stay in the hospital very long, even after a pretty severe injury.

So the primary service providers for kids are families and school. Now, when they go back to school, those who are severely injured, as Janet said, often do get picked up for special education, but one of the things I do in my other life is research, and we're tracking in Oregon all the kids who leave hospitals after being hospitalized for a brain injury and finding that quite a few of them, although their parents report problems, are not being picked up by special education.

And I'm going to talk a little bit about that now. We know that about 60,000 children are hospitalized each year overnight for a brain injury. And if we said that maybe half of those are going to have persisting problems, we would expect to see, and this is a graph looking at incidents, we would expect to see over about a course of about a seven‑year period, which is what this graph represents, 92 to 99, you would expect to see that over the green line that you would see an increase in numbers of kids who have brain injuries and are needing sports in schools.

However, if you look at the identification rates on the US Department of Education census you'd see that over that time there's virtually no increase, it's a flat line.

So those kids aren't being picked up; and that's another presentation why that is. Lots of reasons. And we could speculate. Janet already mentioned that a lot of times the physical effects resolve very rapidly, so it's an invisible disability. Kids go back; they look fine.

And another thing that happens is brain injuries get forgotten. So those of you who work with young children, maybe you are a first grader when you are injured and you go back to school and the support are all there and the community is there and the teacher is really providing structure and lots of support for you, and you do pretty well for a few years.

Well, then you get into sixth grade and things change. The context changes. You are expected to have 7 different teachers, to remember the rules for those 7 teachers, to hand in pieces of paper for 7 different teaches, to keep track of where you need to be, when you need to be 7 different times a day, then all of a sudden some of the organizational and other problems, planning problems come into play, and by that time often we have forgotten about the brain injury.

And so now I'm 12 and I'm struggling at school, and maybe I get picked up with some other disability category, maybe I start acting out and get labeled behavior disordered, or maybe I just struggle and find other ways to make it through school or not.

So there's actually some work being done around this issue, and it's really a big problem because as you all know and epidemiologists will tell us, the numbers really drive services, and as long as we have low numbers in special education census reports, we're going to be off the radar screen.

This next slide kind of shows that. As long as we are under identifying children for special ed, we have all these other problems associated. Then we are know special ed directors within states are saying this is such a low incidence population, there's just hardly any kids out there, there's a lack of awareness, there's not training provided, there's not research dollars provided and as a result our kids are suffering, they are not getting the services and the kinds of supports that they need.

JANET TYLER: Okay. What are some of the long‑term effects of trauma brain injury for our children? This is what we would see often times when a student returns to school following a traumatic brain injury.

Physical issues can be present but like we have said that the physical issues often clear up and so they might actually not have any of those. Generally the physical problems are most prevalent in the first 6 months to a year.

Some of the kind of physical problems that might not be obvious in terms of looking at a person it might be fatigue. These kids often tire very easily, and so they often have to have schedules that are adjusted to meet their needs. And so they may not be able to make it through a full day of school, even though they physically might look just fine that that might be a real pressing issue.

Also we have a number of kids that report headaches, and that's over the long term. And again this might be something that's actually a medical condition that needs to be locked into, but also it might be more of a stress induced headache where the individual just needs to lay down, relax. The pressure of trying to go back to school, trying to pick up activities is often pretty daunting for these kids, and so they have a lot of physical effects from that.

Cognitively, of course, we see a whole host of problems following traumatic brain injury, and these can appear in varying degrees. We know no two brain injuries are the same, and so it's going to be different for each child, but we do see a lot of issues of the frontal lobe.

A lot of our kids have frontal lobe injuries because that's generally if you're in an automobile accident, if you fall, if you're assaulted it's generally from the front and the frontal lobe is often injured, and those are the ones that have the higher order of processing skills, the judgment, the reasoning that initially, like Ann says, doesn't show up in a two year old because we are the frontal lobe for a two year old, it's only when they get into certain age in school they are asked to do those certain things and that's when we start seeing, oh, my gosh, that we're having problems.

Behavior, we get a lot of calls from our project on kids who have behavioral issues following traumatic brain injury. We see kids who had no history of behavioral issues and then following a brain injury might have some problems with impulsivity, lack of inhibition so there might be shouting out, reaching out, saying things that wouldn't be appropriate for their age group. We might have some outburst because of just the sheer frustration of knowing that you used to be able to do something and you can no longer do it.

We do have certain central tendencies within this population, even though we know they are a diverse group. Why they are different from kids with learning disabilities, kids with mental retardation, kids with developmental disability, kids with Attention Deficit Disorder, it is a sudden onset of disability. There is that need for ongoing ‑‑ the medical kind of management, so we have that transition from hospital to school that's very important to set that up and to get communicating early on between the school and the medical community.

We often know that these kids do have ongoing medical needs, they have repeated appointments to go to, they have therapies that they might be going to, a lot of our kids have outpatient therapies when they start back to school, and so there needs to be a coordination for that.

We know that these kids are going to be making progress as they go through the recovery process but it's often really very unpredictable. It may go in spurts, they are going to level off, maybe have some more improvement. It's just very unpredictable.

And actually two people with the same type of brain injury, they might have two kids that are 13 years old, reportedly they both have moderate brain injuries. Both have similar functioning before the jury. They might have different outcomes afterwards. So it's hard to always say what we can exactly predict.

And then we also know that there might be some emotional consequences that go on as a result of the brain injury, not only from the organic ‑‑ actually the brain injury itself, which can lead to some chemical imbalances and might cause depression and things, but we also have kids who have family members that are killed in accidents. We have kids who have lost friends in accidents, they might have to go live with other parents or grandparents as a result of their family's injuries. And so we have a lot of different life changes going or for these kids.

We also might have kids that even if the there weren't any kinds of deaths involved, that after the brain injury, because they are so different, they have really lost their peer group. Their friends who initially have been very supportive move on with their lives, and so we see some depression coming in there. So it's real important to track those kids.

So like we say, with a very diverse population of students, and we know that this enormous variability is due to quite a few different things and thinking about this, your preinjury profile, the age you were at the time of your injury, we do know that younger children have poorer outcomes than older children, you know, that if you have a brain injury and you are going to have to relearn information, it's a whole lot easier to relearn it if you already have that information well entrenched so if you already have learned language and you are able to write and read, relearning those things, but if you are a two year old and you have a brain injury and your brain has not developed appropriately yet, then it's going to be learning information with actually a very damaged brain in some cases.

The level of education, we do know that those kids who have better educational history success do better after a traumatic brain injury.

A lot of information has come out with the concussion in sports information I find real interesting that when they do these studies of the college football players, they look at them before the season, test everybody before the season, then watch for the concussions and then test them after their concussions.

Well, what they are finding out is that those kids who were identified previously with any kind of learning disability or Attention Deficit Disorder, that those kids with these mild concussions do much worse, they show more severe types of neurocognitive effects after a concussion. So that kind of preexisting behaviors might kind of tip them over the edge.

And certainly our kids that have a history of behavior problems, certainly those are exacerbated by the brain injury. And of course a lot of the kids we see have a brain injury because of their behavioral issues. They might be the kids that were normally more impulsive and ran out in the street, they might be the kids that were involved in drugs and alcohol, running away from home, stealing cars, those kinds of things. So oftentimes that those kids do end up having brain injuries.

Okay. Talking about normal development. And we've got three different slides in here, and we don't have them sided in we wanted to make sure we acknowledged them. These are from Sandy Chapman from the University of Texas at Dallas, and that should be down in the corner, and we noticed that it wasn't there. But thanks to her for these slides.

You can see that normal development going along without a brain injury and then looking at what happens when that brain injury occurs. So we have a kind of a drop in where the normal development should continue with the brain injury. And we do see that okay, you start going back up on that curve and then you have some leveling off. And if there's not interventions, then we don't see the child developing at the same rate. And so what you see happening is actually the gap between where the child is with the classmates starts getting wider and wider.

Ann talked a little bit about missing those kinds of brain injuries that occur at an earlier age and not thinking about, you know, this is maybe why the child is not reaching those milestones, why they are not talking age appropriately, why they are not gathering their math facts. And looking back, and it might be a history, an unreported history of abuse.

We do know a lot of the kids that are taken out of abusive environments, but we might not equate that with a brain injury. I think the figures are 80 percent of the kids who are abused have brain injuries. And so if you have a child that's from an abusive home, is in foster care or whatever, even though we might not have a documented history of a traumatic brain injury, we should look at assuming that maybe that is the case.

So you're really missing some of the major milestones. It's like the foundation is cracked, you're trying to build this brain, but the foundation is cracked, and so you're going to have some real issues as you go along.

And so looking at what can we did to help the students, we want to make sure that we are certainly concentrating on that initial aspect of the brain injury when that child first has it and going back to school, but also continuing to provide the intervention as the child goes along and so that we are making sure that that normal development does occur.

We talked a little bit about the severity of the brain injury. I think I said that earlier that we know that just that the medical definition of traumatic brain injury doesn't always equate with long‑term outcomes. Certainly we know that kids who have sometimes mild injuries may still have needs, too.

The location of the brain injury will cause certain effects. We talked about the frontal lobe having problems, but then we also know that there's a lot of diffuse injury, and so you can't really equate saying okay since he had temporal lobe injury, these are the effects that are going to happen, because we know while, yes, there are some major centers in certain parts of the brain that we can identify, we also know that the brain is really very interconnected, and so your memory is just not all in one spot, your vision is not all in just one spot. So there's different areas that can be affected.

Another thing that we know that will cause a difference in how a child, the outcome after traumatic brain injury is the level of medical care and rehab that they get.

Now, they talk about the golden hour of getting to the hospital after a brain injury if you're an adult that's injured, and so it really needs to talk about the platinum half hour of getting a child to the hospital following traumatic brain injury because we do know that kids react very much quicker, their blood pressures drop and their heart rates, all those things are much more volatile in young children. So we want to make sure that those kids are being seen right away.

We do have, you know, over the years, gosh, since I started 18 years ago, the medical care that kids can get has significantly improved. We are saving a much more severe population of students. We are not keeping them in the hospital nearly as long as we used to.

When I first started, if a child had a severe traumatic brain injury, they were in the hospital for 6, 8 weeks, you know, several months. Now, I mean they are out the door and back in the school.

We had one young man who had ‑‑ was having to have a hemispherectomy because of a rare seizure disorder, he had Rasmussen's encephalitis, and so it was kind of a progressive type seizure disorder, and so they had tried everything. They were going to have to do a hemispherectomy, actually remove half the brain.

In talking with his mother, the insurance company preapproved this young man for three nights in the hospital. Needless to say, he wasn't still awake after three days but honest to goodness within the week he was back at home and then back to school shortly thereafter. So this is kind of immediate turn around.

So the kids aren't getting a lot of long term care in the hospital, they are back in the community, they are back in your all services, in our school systems, and so we really need to be the ones that address the issues.

For our kids that in like, for example, in

Kansas, if the you're in the Kansas City area or the Wichita area, there's lots of great places to go for rehab that specialize in pediatrics. You get out in western Kansas and there is no one that specializes in pediatric, and I'm sure that's true of many other states when you get to the rural areas, and so you know the availability of the care that you get following the brain injury is really going to make a difference long term.

And then what kinds of support you have following not only medical support but just long terms kind of family support. A lot of our kids don't have ‑‑ didn't have a lot of support to begin with, and maybe that's why they were injured, they weren't supervised, weren't cared for.

And we know the studies show that for even adults the more support you have the better you recover. And so that support can come in many forms, it cane come in the form of your family, it can come in the form of a church group, neighbors. But those kinds of supports are needed to help improve, they certainly improve the child's outcome.

So on those kids that don't have the good supports in place, the schools and other community service agencies have to work that much harder to try to provide those kinds of supports and help improve the outcomes for those kids.

Now, talking a little bit about developing educational programs, what we do with these kids when they are back in the schools, and we know they do have kind of complex issues in many cases, their characteristics are very different from other kids with other disabilities.

They have variability in functioning. They do required specialized program for these kids. But we know that, like I said, the diversity of the population is such that we don't really have any kind of a set TBI or program or curriculum.

I have had parents come up to me and say I really wish my school would get a TBI class or TBI program, and I say you really don't want that. There isn't a best method or program for an individual ‑‑ I'm sure that sounds wonderful on the recording ‑‑ no best program that we can recommend.

Really what we need to do is look at what the child's needs are. I mean that certainly is what we should do for every student, but look at specifically what the child's needs are. And we will see in a lot of cases that a student with traumatic brain injury we can identify certain characteristics, the student has memory issues, the student has attentional issues.

Well, then we can look at where is the research that looks at either other kids with exceptionalities that have those same kinds of issues or just in general what does the research say on memory or what does the research say on children with attention deficit disorder. Those areas have been more highly researched.

You know, it's really hard to research a population of students with traumatic brain injury because of all of those variabilities that we mentioned, trying to get a large end study of kids that all have the same level of brain injury that are all the same years post injury is next to impossible, so we don't have a lot of research in the area.

But what we do have is research on good effective teaching practices if we can go back to that and pair what the students' needs are with those kind of research based, you know, No Child Left Behind really addresses researched based teaching methods. And so that's where we are going to need to look.

So identifying students needs, pairing them with the research based strategy and then more so than any other student we are going to have to continually assess, because we know especially initially right after the injury, those kids are going to be making such rapid progress, you set up a program one month it's going to be a different child that you are serving the next month. And so constantly having to readjust that. And also knowing that not every strategy is going to work and so we are going to have to constantly readjust, if that strategy isn't working at that program then we are going to have to look at it, see if it's effective, and adjust if the it's not.

ANN GLANG: So when we start talking about educational programming and we remember that kids in general with brain injuries are sort of off the radar screen of teachers in schools, we want to talk a little bit about that.

First of all, most teachers teaching today did not in their training programs get any information about brain injury. About 8 percent of graduate level special education training programs actually cover brain injury as part of the content.

So what we have are a lot of folks who are teaching in schools, whether they are recent graduates or have been teaching for a long time, not having any information from the pre-service education on this population of kids.

We know from some work we have done just sampling educators and doing some knowledge quizzes and some measures of how competent they feel, that teachers don't feel like they know much, and actually they don't know much, on some knowledge quizzes that we have given.

And in general a couple years ago we gave a survey of about 185 educators and asked them how prepared do you feel to handle academic, behavioral, social and physical needs of kids with brain injuries, and on a scale of one to five the average rating was right about a three; so really feeling not very competent, somewhat competent.

So they just don't have the experience and some, typically where people get the experience is by having a student and by doing what that last slide just showed, which is some good assessment, some good instruction, some checking in and seeing how the students going and learning on the job.

This is a quote from a fifth grade teacher who worked with a student of brain injuries. She said he's the only identified child with TBI, and we don't know what to do with him.

I want to tell you about another student who is from Oregon who in the first grade was in the care of his aunt and ran across one of those two‑lane highways and was hit by a car and had a severe brain injury. Went back to school.

He had he had been a very bright student and promising kid, you know, early reader, very articulate, language was really solid, doing well in math. His family had very high expectations for him, came from a family that was unlike some of the families Janet was describing, a family where both parents had graduate degrees and they had high expectations for this young boy.

And really their hopes were dashed when he was injured. So he is now 7, he's in first grade, and his mom says the teachers say David is fantastic, he's such a joy. He's a little slow. But that's David now. They don't know David as any way else.

So from the family's perspective, they are saying you don't know my son, he's different than who he was ‑‑ he's different now than he used to be.

And then his mom says I don't know if the information about his brain euro got passed along to next year's teacher, it's in his cumulative file, but I don't know if anyone reads those. Well, how many teachers take time to go to the office, take the time to read the thing that's you know three and a half inch inches thick? Probably not. So there's a theme of communication between family and school and within school for these kids.

And then his teacher said I had no training in the TBI, kind of like Trevor's teacher. It was tough, I wanted to push him, but it didn't want him to get frustrated and shut down. So there's this fear of teachers, I think of pushing children, and particularly I've had teachers say I just don't know if I should correct him, maybe I shouldn't correct him. Because they are afraid they are going to damage the child further. And there's just a lot of misconceptions an myths around how to serve these kids.

So people need training, and that's what we are going to focus on for this last little bit of our presentation.

When we say who needs training, pretty much everybody in a school who touches the child needs to understand something about the brain injury. And I was struck; it was like two months ago I was watching a football game on TV.

What's in the public media about brain injury? I'm watching this show, this player gets hit, has ‑‑ gets hit clearly on the head in this tackle, and the announcer says ‑‑ and the guy gets up. The announcer says well, he really got his bell wrung but thankfully he didn't get a brain injury because he didn't have a concussion.

So this is the information that goes out to the public, right? And Janet just pointed out doesn't take a coma for a brain injury to happen. And so there's just not much information. And sports is probably the worse, it's probably the most widely available form of education for all of us.

So everybody who works with a child who watches sports especially needs training.

It is now mandated in No Child Left Behind that training is high quality. And what that means is that it's different from how it used to be in schools and still is in lots and lots of schools actually that it's more than just a one‑shot training.

Typically what a school district will do is say let's have a training on whatever it is, autism, and it's a one‑shot thing. Everybody gets out of their class. Teachers are happy to have the day to go to a training and get a break from their very, very difficult jobs.

But it's most staff development research has shown that a teacher who goes to a one‑day workshop retains about 10 percent of what they hear and implements about one percent. So it's not an effective way. So the actual ‑‑ it's not federally mandated that we need to have sustained intensive classroom focused kinds of trainings.

A few years ago Mark Ilvasocker and a group of authors who had been working with kids with brain injuries in schools for a long time put out some recommendations, and I'll just go over these briefly, that training should really relate in practical ways to everyday classroom interactions; that it should be ongoing, not just come in, give the presentation and leave; that it should involve hands‑on work, specific teachers assignments and intervention experiments with concrete feedback, so asking teachers try this out, try out this research based strategy, and then let's talk about how it went and kind of doing some hypothesis testing around that; that it needs to be consistent with the school's culture and constraints on teachers' times and meet the objectives of those seeing help.

So when a teacher is feeling very frustrated with a child's behavior, they need a workshop on behavior management, they don't need a workshop on communication or on brain anatomy. They need information that will help them. Teachers don't have time to have a lot of extraneous information. And then finally that it needs to result in improvement in the student's performance.

So we want to talk about a model that has been implemented in these seven states, and Janet and I both have been involved in and continue to be involved with in our two states, Kansas and Oregon, and this model, the TBI resource team model, really does try to incorporate those recommendations both from No Child Left Behind and from that article that I just mentioned.

It's a cost‑effective model to build statewide capacity, and the idea behind it is that we have tried to train a team, a cadre of consultants who know something about brain injury who can go out then and be available to provide training and resources for teachers working with kids in classrooms.

So talk a little bit about ‑‑ and there's lots of places you go to get more information about this, so I'm going to just hit the high points here.

In terms of team membership, in our states what we have done is gone out to recruit school‑based folks. This is important for several reasons. One of them is school‑based folks understand schools, and you need to have that understanding to really be able to be helpful to a classroom teacher.

We in our ‑‑ in both of our states, we have adjunct representatives from community‑based and medical organizations. We have some hospital‑based folks who serve as adjunct members. But in general we try to get these folks from within schools to participate.

We want to get the capacity of local schools built up.

We are not concerned about the capacity of hospitals to deal with kids with brain injuries, we are concerned about schools, and so we have tried to recruit school psychologists, nurses, counselors, a parent to participate in each of our states, each of those seven states actually to get the training so that they can then go back and provide ongoing training and support to folks.

So our team members participate in an intensive training. It varies from about 8 to 15 full days of training. The topics are ‑‑ so it's not a one‑shot thing. The topics are all of these here, big focus on behavior management because that's what drives teachers crazy, academic success, helping kids stay organized, all these strategies for working with kids in the classrooms. And then lastly, we do some work on how as a team member you can be an effective consultant, how to do a good presentation for a school, how to go in and work with a school team with kids, a kid in a classroom.

Talk a little bit about the impact of this model. First in terms of just some of the activities ‑‑ two of the states I have data from last year, I just put two sample states up here. In Arizona 90 trainings were held last year, about a little over 2,000 participants, Kansas 52 and a little over 1,000.

And what these trainings are doing is really building awareness locally within the state of this population. So our team members are going out and doing kind of the same kind of presentation Janet did for you to talk a little bit about what brain injury means, how common it is, and how it shows up in the schools.

And if you think about this, in Arizona, for example, prior to this, the year before, there were no trainings and no teachers and school‑based folks learning about brain injury.

You look at the number of kids being served, lots of kids who are having somebody who knows something about brain injury work with their school team, and that makes a difference in terms of the kinds of services then that are offered to the child because it's more sensitive to the issues that face kids with brain injury.

This is from Arizona where we broke down our team members' activities by numbers of kids that they worked with both on and off their caseloads. So we ask our team members to work, you know, they continue to work with the kids who they are already serving who have brain injuries, but then we ask them to go above and beyond and to work with kids who are off their caseloads.

So they get permission from their supervisors to work for about a total of eight days throughout the school year and they get release time from that to do that, to work with kids off their caseload, and in Arizona you can see the green bar as the number of kids that they are working with who ordinarily they wouldn't have seen it all.

Types of support provided. More often than not it's onsite consultation, which again is consistent with what we saw on the slide before about recommendations. We really try to get our team members to go into schools, walk into the classroom, observe the child, talk with the teacher, problem solve with therapists working with a child, talk with the family, phone consultation as well. They are doing some assistance with evaluations, very rarely doing direct service, and sometimes disseminating information and materials.

And then if you look at the frequency, number one of the recommendations was that this be ongoing. So our ‑‑ the average there I think is around three or four visits to a child in a school. So we try to encourage people to not just go once or twice but to keep coming back and to check in with the school team and make sure things are going well.

And we see that some of that far right bar, some of our team members going in more than 11 times. And I'm imagining that those are ones that are on their caseload.

This is the number that I'm the most excited about. In southern Arizona we did this really big effort to provide training to recruit team members from within the southern part of the state and looked just recently at what happened to identification rate.

So our kids being picked up for special ed who weren't before, and, in fact, yes, in 2000 we had 93 kids in this one geographic region of southern Arizona being picked up for special ed labeled as traumatic brain injury; 2003 it more than tripled to 374.

So the hypothesis there is that as the training gets out to people in schools making decisions about special ed and looking at kids and their needs, that training influences their thinking around, oh, maybe I need to ask some questions about brain injury or maybe that injury that I see on their chart from five years ago is showing up now. So we're starting to see some different things happen in terms of identification, which is very exciting.

Talk a little bit about what states need to be able to pull off this model, really, really critical to have Department of Education support. In both of our states we started out with grant funding from the Federal Department of Education, and in both cases our state departments of ed then picked up the financial support of the team and said you have made a case that this population needs some attention.

We have autism coordinators, we have death‑blind coordinators, we have coordinators for this and that, and now in several of these states we have traumatic brain injury more on the radar screen. The majority of states do not have this. Most states do not have somebody at the state department of education identified as this is the coordinator. We are working on that.

JANET TYLER: Or if they do, they don't have much knowledge in the area.

ANN GLANG: If they do have a coordinator, that coordinator may not know much about brain injury.

Thirdly, you need the training budget. So you know this is done differently in lots of states. In Oregon we do it very inexpensively, because we call on local resources, we call on people who have expertise who don't charge an arm and a leg to come in and do some workshops.

And then you need to have some funds to support release time so that school‑based staff can leave and go to the trainings.

In terms of maintaining the model, a couple of key points. It's important to have the kinds of evaluation that we ‑‑ I was able to show you today to show that, yes, this is making a difference. The department of ed support I have already talked about.

We really feel ‑‑ I really feel like you have to have somebody who coordinates. You have these team members. They all have other day jobs. They are all really, really busy. A lot of them, especially special ed folks following lots and lots of kids with lots of needs.

So for them to have to ‑‑ if we ask them, for example, if I'm going to call up someone in Bend, Oregon, and say one of my team members say I'd really like you to do this training for a school, there's a new child being discharged from the hospital, I'd like you to go in and do this training, I can't ask her then to do all the logistical support, so we do that centrally from the state department of education where we offer, we send handouts and organize the site and so on.

And then I know Janet has been really good in Kansas about having annual meetings, trainings for her team members to keep them up to date with research. We try to do that one to two times a year.

And in our state we have about 25 to 30 people over the 15 years or so we have been doing this, 25 or 30 people who are still very regular team members, who we call upon on a regular basis to go out and work with schools. So we pull them together a couple times a year and let them network with each other, talk about difficult cases as well as get some continuing education.

Some of the advantages, it's really easy in both of our states to know there's one place to call to get some help. So a school district knows there's this 1‑800 number or website or email address to contact.

We try really hard to focus on local capacity, and again that's by having the school‑based folks involved throughout the state. The other thing, and Janet talked about the overlap across disabilities groups, many, many of the skills and strategies that our team members learn are applicable to any disability group and really just depends on what the functional challenges are of the child.

And forth advantage is obviously raising awareness, and I think we are seeing that reflected in our identification rates in Arizona. Some of the challenges our team members are really busy, so they are already working 40 hours a week, and then we ask them to do a little extra. We do pay them some extra if they do on their, we have some stipend so we can did that. But it's hard with such busy lives.

We have some schools who really don't want help, and that's, you know, just the way it is, they feel like we can handle this; and yet sometimes we hear from the parents that, well, my child isn't being well served. So sometimes we have some frustrations around that.

It's hard in all of our states, I mean pretty much every state in our country has interesting geographic distribution where you have population centers in one part of the state and then you have these large rural areas, it's very hard to cover the whole state with one model like this.

And then the fluctuations in fiscal support. In Oregon we have gone from having pretty good funding to having nothing, to, you know, it just goes up and down. And so we try to keep things going in spite of the funding, but that is also a frustration.

The last slide I think here is just this idea that if you can improve the training, build the awareness of folks in schools, you can start to have an impact on these other spheres around raising awareness, around getting more funding.

And I think we have seen this, I think Arizona is a really good example of this, because they took this model on and implemented it, had the foresight to before the fact say this is the model we want to continue with state funding, we are able to make that happen, and so now we are starting to see things like identification rates go up.

So we are really seeing the system change, and that's been very exciting.

We do have some material ‑‑ places that if your state is interested in looking at doing some trainings and getting more information, we have this and we can send it to you, some information, some websites where you can get some good information.

And I guess that was it. Was there another one? That was it.