Brain Injury Professional, vol. 3 issue 4

B R A IN INJURY professional vol. 3 issue 4

The official publication of the North American Brain Injury Society

Special Issue on Pediatrics and TBI Neurocognitive Stall: A Paradox in Long term Recovery from Pediatric Brain Injury Research Update: The Child and Adolescent Scale of Participation The Use of Personal Data Assistants (PDA) with School-aged Students with Cognitive Challenges A Holistic Approach for Improving Educational Outcomes of Students with TBI: Promising practices and new directions for research Outcomes and Assessment in Childhood Traumatic Brain Injury Neuroscientific Principles Underlying Reorganization After Brain Injury Promising Practices for Youth with TBI Transitioning to Adulthood

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contents

BRAIN INJURY professional vol. 3 issue 4, 2006

The official publication of the North American Brain Injury Society

north american brain injury society

departments 4 Executive Vice President’s Message 6 Guest Editor’s Message 8 An Open Letter to the Editors of Brain Injury Professional 19 Professional Appointments 36 Non-Profit News 38 Conferences

chairman Robert D. Voogt, PhD treasurer Bruce H. Stern, Esq. family liason Julian MacQueen executive vice president Ronald C. Savage, EdD executive director/administration Margaret J. Roberts executive director/operations J. Charles Haynes, JD marketing manager Joyce Parker graphic designer Nikolai Alexeev administrative assistant Benjamin Morgan administrative assistant Bonnie Haynes

brain injury professional publisher Charles W. Haynes publisher J. Charles Haynes, JD Editor in Chief Ronald C. Savage, EdD founding editor Donald G. Stein, PhD design and layout Nikolai Alexeev advertising sales Joyce Parker

EDITORIAL ADVISORY BOARD

features 10 Neurocognitive Stall: A Paradox in Long term Recovery from Pediatric

Michael Collins, PhD Walter Harrell, PhD Chas Haynes, JD Cindy Ivanhoe, MD Ronald Savage, EdD Elisabeth Sherwin, PhD Donald Stein, PhD Sherrod Taylor, Esq. Tina Trudel, PhD Robert Voogt, PhD Mariusz Ziejewski, PhD

editorial inquiries

14 Research Update: The Child and Adolescent Scale of Participation

by Gary Bedell, PhD, OTR

Managing Editor Brain Injury Professional PO Box 131401 Houston, TX 77219-1401 Tel 713.526.6900 Fax 713.526.7787 Website: www.nabis.org Email: contact@nabis.org

16 A Holistic Approach for Improving Educational Outcomes of Students

advertising inquiries

Brain Injury

by Sandra Bond Chapman, PhD

with TBI: Promising practices and new directions for research

20 Outcomes and Assessment in Childhood Traumatic Brain Injury

by Keith Owen Yeates, PhD

Joyce Parker Brain Injury Professional HDI Publishers PO Box 131401 Houston, TX 77219-1401 Tel 713.526.6900 Fax 713.526.7787

24 The Use of Personal Data Assistants (PDA) with School-aged Students

national office

by Ann Glang, PhD and Marilyn Lash, MSW

with Cognitive Challenges

By Yvonne Gillette, PhD 26 Neuroscientific Principles Underlying Reorganization After Brain Injury

by Cherie R. Percaccio, PhD and Michael P. Kilgard, PhD 30 Promising Practices for Youth with TBI Transitioning to Adulthood

by Bonnie Todis, PhD, James Malec, PhD and Jane Gillett, MD-FRCP(C)

North American Brain Injury Society PO Box 1804 Alexandria, VA 22313 Tel 703.960.6500 Fax 703.960.6603 Website: www.nabis.org Brain Injury Professional is a quarterly publication published jointly by the North American Brain Injury Society and HDI Publishers. © 2006 NABIS/HDI Publishers. All rights reserved. No part of this publication may be reproduced in whole or in part in any way without the written permission from the publisher. For reprint requests, please contact, Managing Editor, Brain Injury Professional, PO Box 131401, Houston, TX 77219-1400, Tel 713.526.6900, Fax 713.526.7787, e-mail mail@hdipub.com

BRAIN INJURY PROFESSIONAL

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executive vice president’s message Brain injury in Children & Adolescents – a Developing Disability Dr. Roberta DePompei and colleagues who attended the Galveston Brain Injury Conference in Galveston, Texas last Spring, 2006 have assembled the collective research and experience of many national experts on traumatic brain injuries (TBI) in children and adolescents. NABIS wants to thank the Moody Foundation for sponsoring this wonderful opportunity.

We know that too many of our children sustain TBI’s each year in motor vehicle crashes, falls, sports and recreation activities, assaults and abuse. The Centers of Disease Control and Prevention (CDC) reports that among children up to 14 years of age, TBI results annually in an estimated 2,685 deaths, 37,000 hospitalizations, and 435,000 emergency department visits (Langlois, RutlandBrown, & Thomas, 2005).

Rates were highest among children aged 0-4. For Ronald Savage, EdD children under 10 years old, both death and hospitalization rates are significantly higher than other age groups.

Thus, based on the CDC estimates, approximately 1.7 million children sustained a head injury serious enough to be referred

Galveston Brain Injury Conference In 2000, the University of Texas Medical Branch chose to establish the annual Robert L Moody Prize for Distinguished Initiatives in Brain Injury Research and Rehabilitation. The purpose of this award was to honor Robert Moody’s legacy of promoting progress in rehabilitation education, service and research. This $10,000 juried cash award would go to individuals or groups whose efforts have made significant contributions toward (1) advancing clinical research in acquired brain injury, (2) developing new treatment and rehabilitation procedures for individuals with acquired brain injury, and (3) increasing awareness of the needs for treatment of individuals with acquired brain injury.

To further this initiative, and provide the appropriate venue for the presentation of this award, UTMB and the Transitional Learning Center at Galveston developed the framework for the annual Galveston Brain Injury Conference. Themes would be chosen, and then national and 4

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to an emergency department during the past four years – certainly a number too big for us to ignore.

Unfortunately, as we all know, children with traumatic brain injuries grow up to become adults with brain injuries.

Traumatic brain injury in children or adolescents is a developing phenomenon. As children’s brains continue to develop and mature, the earlier damage to their brains often leads to long term deficits as they get older. These deficits often worsen at the same time that life becomes more demanding. Each new developmental milestone becomes more challenging as new skills and behaviors become harder to learn, especially those skills and behaviors required for adulthood. Because so many youths with complex brain injuries experience chronic, life-long disabilities, the costs of these disabilities in terms of individual suffering and loss, family burden and stress, and financial burden to society can be overwhelming.

Fortunately, new research and new practices are helping us focus our efforts on behalf of children with TBI. We know that neural plasticity is much more complex than we previously thought. We know that pediatric TBI is not a low-incidence population. We know that mild TBI or concussion in children may be more complicated than just a bang to the head. We know that younger children, especially those ages B-10 years, are more likely to get TBI’s than our teenagers. And we know that prevention works and is still the only cure for TBI. With all this new information, and thanks to Dr. DePompei and her colleagues, we have a unique opportunity to make a difference in the lives of children with TBI and their families.

Ronald Savage, EdD international experts would be invited to meet in an informal setting.

The Moody Prize would then be awarded at an evening banquet.

The topic for the first two years of the conference was the development of minimal data sets to be obtained at each stage of the brain injury continuum—from the ER to home.

The results were published in Brain Injury, 2006. The next two years, under the leadership of John Whyte, MD, PhD and Tessa Hart, PhD, the focus was on characterizing treatments in TBI rehabilitation: to peer into the “black box” of TBI rehabilitation. The product of those two years was published in the March-April 2006 edition of the Journal of Head Trauma Rehabilitation. Under the leadership of Moody Prize award winner, Roberta DePompei, PhD, the 2006 and 2007 topic is pediatric TBI. Recipients of the Robert L. Moody Prize are: Mitchell Rosenthal, PhD, Jeffrey Kreutzer, PhD, Marilyn Spivack, Roberta DePompei, PhD, Barbara Wilson, PhD. Readers are encouraged to submit nominations for the Robert L. Moody Prize at www.2.utmb.edu/TLC/MoodyPrize Brent Masel, MD

guest editor’s message Making a Difference for Children and Youths with TBI “Despite the fact that, annually, over 200,000 Americans become disabled from a traumatic brain injury, it is an ‘orphan’ disease — largely ignored by the public and the medical field — and if adult TBI is an orphan, then child TBI is the orphan of the orphan. Their needs are left unmet by the medical field, insurance industry and the school systems” (Masel, 2006).

Children and adolescents who sustain TBIs are often not recognized for the altering affects the injury can have on learning and life long living. This issue of Brain Injury Professional focuses on innovative ideas that can influence how children are supported after a TBI. These articles were stimulated by the Galveston Brain Injury Conference (GBIC) which was held in Galveston, TX on May 47, 2006. This invitational meeting focused on the chosen topic of issues affecting children with TBI and was supported by the Moody Endowment. The annual GBIC was initiated in 2000 as a means to address gaps in research and Roberta DePompei, PhD treatment efficacy identified at the NIH Consensus Conference on TBI. The May 2006 GBIC meeting was the first time that children and adolescents were the primary group for discussion. While there were many important topics that could have been addressed by the participants, the focus was narrowed to four topic areas: 1. neuropsychological, neurophysical issues that affect development and learning; 2. assessment and outcome; 3. school reintegration and strategies to help the child be successful academically and socially, and 4. transition into adulthood. The mandate to participants was to not spend time talking about what the problems were but to share what innovative approaches, treatments, and promising practices are presently available. Experts who represented numerous fields of specialization were invited to participate in the group discussions and encouraged to provide thinking outside the box that could move the issues of children and adolescents for-

6

BRAIN INJURY PROFESSIONAL

ward. The four group leaders were Drs. Sandra Chapman, Keith Yeates, Ann Glang, and Dr Bonnie Todis.

This issue provides a summary of the main ideas that were discussed in each of the four groups: neurocognitive stall and how developmental issues impact the long term recovery after TBI; use of the International Classification of Functioning, Disability, and Health as a framework for conceptualizing outcomes of childhood TBI; educational needs of students with TBI that are important to furthering research and program development; and the pressing national need for services to improve transition outcomes for adolescents with TBI. The topic of plasticity and neuronal stimulation after injury emerged within several groups. Drs Cherie Percaccio and Michael Kilgard provide an article that outlines their work on the self organizing capacity of the cerebral cortex and the cortical reorganization that occurs in response to injury. There are also several research updates from individuals who are working with youths after brain injury..

It is helpful to recognize that children with TBI will grow up to be adults with TBI. Many times, when appropriate services are not offered to these children and adolescents, they grow up only to be involved in adult mental health, welfare, or penal systems.

The cost for working with these children as adults may be much more in terms of financial, social and emotional efforts than if they had been correctly identified and supports placed around them early on. It is my hope that these articles stimulate others to think about the issues challenging children and that movement to facilitate change for these children continues in both research and clinical arenas.

The next meeting of the GBIC in April, 2007 will extend the work by these experts and focus on articles submitted from a Call for Papers on these critical issues. The results of the second conference will be published in a special edition of the Journal of Head Trauma Rehabilitation in 2008. Many thanks to JHTR and the Moody Foundation for their support of this important work.

Roberta DePompei, PhD References

Rehabilitation of persons with traumatic brain injury: NIH Consensus Statement Online.1998: 16(1) 1-41.

Masel, B (2006) Opening remarks Galveston Brain Injury Conference. Galveston, TX: May 5, 2006.

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an open letter to the editors of brain injury professional Dear Dr. Savage: I am writing about what I believe are extravagant, unreasonable and improper charges being made in neuropsychological evaluations done in the name of ‘forensic neuropsychology’ in cases of individuals with acquired brain injury. I believe that this needs to be discussed openly, in a publication like Brain Injury Professional, and that through a public forum, some guidelines and standards for reasonable compensation within forensic neuropsychology be developed and published.

I believe an open and public forum on this issue is desperately needed and what is occurring has the potential to undermine the entire process of neuropsychological assessment and consultation in the evaluation of patients with acquired brain injury. I believe it is also undermining some of the research in TBI as it relates to neuropsychological outcome following TBI. It is also having a damaging effect on patients with brain injury who are in the litigation process.

As a professor who has directed clinical neuropsychology subspecialty training for thirty years and a practicing neuropsychologist for 32 years, I have personally witnessed the emergence of clinical neuropsychology as a critical discipline within the multidisciplinary approach to the evaluation, care and treatment of patients with traumatic brain injury (TBI).

As is obvious and well understood, many sustain a brain injury through no fault of their own as a result of motor vehicle accidents, assaults, falls, work-related injuries, etc. New cases of these types of injuries occur by the hundreds of thousands of times annually, as substantiated by Center for Disease Control statistics. If someone or some circumstance is at potential fault for the accident or injury, litigation typically ensues and so it is no surprise that neuropsychologists and other health-care professionals who deal with brain injury are brought into the litigation process. Likewise, the very nature of what a neuropsychologist can assess has particular relevance for loss of cognitive and behavioral function as a consequence of injury, which in many respects may be the key aspect of the entire litigation process. As such, like many neuropsychologists I have considerable experience with forensic work, because the majority of patients that I have seen have had some type of acquired brain injury.

In the beginning, there was no such thing as ‘forensic neuropsychology’, but just clinical neuropsychology. Patients were evaluated as part of some clinic or assessment center or an individual’s private practice with findings reported to the referral source whether it be another healthcare provider, agency or an attorney. Billing for such services would be at the standard rate for clinical assessment. Significant restrictions on the total amount of hours billed for neuropsychological services began to change in the late 1980’s and now there are significant caps on the amount that can be billed and for what services.

If one searches the National Library of Medicine (www. pubmed.gov) with the key words of ‘forensic neuropsychology’ the oldest reference is 1983. In the 1980’s few clinicians referred to themselves specifically as ‘forensic’ neuropsycholo8

BRAIN INJURY PROFESSIONAL

gists but that has now become commonplace and may even be the title the practitioner uses on their stationery, listings in the phone book and other directories, as well as their office moniker. The full-time ‘forensic neuropsychologist’ has a very different role than the typical patient-focused clinical neuropsychologist providing frontline patient services. No longer is this a neuropsychologist-patient relationship in a primary sense, but rather a neuropsychologist-attorney relationship.

This changed the nature of billing for such services, essentially moving to a consultation service model rather than a patient and insurance-based reimbursement model. In the world of insurance reimbursement, depending on the region, the procedure, presenting problem and diagnostic condition such services can be billed somewhere between approximately $100 - $300/hr. Most insurance carriers have caps on the total hours that can be billed for assessment, and often pay less than the hourly rate typically charged by the neuropsychologist (i.e. a negotiated rate with the provider to be on their panel). For example, here in Utah no insurance panel that I am on permits more than a total of eight hours, which includes everything – interview, testing, report and feedback. I can also say that few cases are approved for eight hours, more commonly approved in the four to six hour range, with the insurance carriers generally reimbursing at approximately $150/hr.

It appears to me that excessive billing practices for ‘forensic’ work are on the increase. I have four depositions of cases where the neuropsychologists retained by the defense have billed on average about $25,000 per evaluation and by the time the case settled two of these were in excess of $40,000 of total charges. The case that prompted my writing this letter is one where the initial charges totaled $27,750 for a single assessment by a ‘forensic neuropsychologist’ performing a defense examination of a patient with a well documented brain injury. The bill is outlined in Figure 1.

This was not a case of trivial injury. The patient had sustained a significant brain injury associated with multiple skull and facial fractures and positive loss of consciousness with several days of post-traumatic amnesia. There were other complications including a pulmonary embolus that required treatment and delayed carotid dissection resulting in left hemisphere infarction and dysphasia and right-side hemiparesis. The patient spent just under two months in the hospital before being discharged to a rehabilitation center for out-patient care. The patient’s hospitalization was at a Universitybased Trauma 1 center.

I understand the legal process, that it is adversarial and that there are two sides, simultaneously attempting to prevail. I also understand that neuropsychologists need to bill for consultation work they do and that in complex cases involving litigation, significant charges can accrue. I also recognize that because of a host of reasons, consultation charges for forensic work can be higher than the typical reimbursement rate for insurance billing of similar services. There are multiple layers to every issue, and both sides in a legal argument are entitled to consultants to assist them in their legal strategies and the

Figure 1

Actual Bill

This is the actual bill rendered by the neuropsychologist at the time of deposition. The neuropsychological examination was $3,000 with another $1,500 for ‘test interpretation’. The remainder of the charges are for records review and report preparation. With any insurance based reimbursed the report is expected to be part of the total charges. As mentioned above, the patient was hospitalized initially for just under two months and had several weeks of inpatient rehabilitation, followed by approximately 18 months of community based rehabilitation. While the records are rather voluminous, the critical elements of the record are straightforward. As a requirement of any hospitalization, an admission and discharge summary is always generated that overviews the hospitalization. The initial hospitalization was in a University based Level 1 trauma center, with a very well organized chart that would be expected from such a medical setting. Note that there are seven days where this neuropsychologist spends five or more hours per day either reviewing or preparing the report and bills accordingly.

consultants are entitled to bill for these professional services.

With that said, there are ‘reasonable and customary’ charges for such services and then, as in this case and others, there are exorbitant charges. What is now occurring is that ‘forensic neuropsychologists’ are performing ‘evaluations’ and using this format to generate long and elaborate consultative reports, designed to negate whatever the findings are of the other side, in particular front-line clinicians working directly with the patient. Incredulous billing practices are now occurring and the amount of money being generated begs the question of creditability of what is being accomplished.

Recent surveys show that ‘forensic’ work has become more and more a mainstay of clinical neuropsychological practice,

yet there are no agreed upon standards, and in particular I am not aware of any public forum that has addressed billing standards. Since economics are key issues in any profession and also represent the area where the greatest abuse can occur, I recommend that Brain Injury Professional tackle this forensic issue.

Sincerely, Erin D. Bigler, PhD Professor of Psychology and Neuroscience Brigham Young University Department of Psychology erin_bigler@byu.edu BRAIN INJURY PROFESSIONAL

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Neurocognitive Stall A Paradox in Long term Recovery from Pediatric Brain Injury

by Sandra Bond Chapman, PhD Acknowledgement Special thanks for the leadership and comments from the Neuro- group at the Galveston Brain Injury Conference – including Drs. Mark Ashley, John Corrigan, Roberta DePompei, Guinevere Eden, Steven Flanagan, John Hart, Flora Hammond, Michael Kilgard, Deborah Little, Brent Masel, Jamie Williams, and Dennis Zgaljardic. Also special gratitude to Mary Margaret Burkhalter and Jacque Gamino for their help in editing.

Introduction One of the most devastating events for a family is when their child suffers a severe traumatic brain injury. The whole family’s life as they know it is disrupted in an instant. An acquired brain injury may occur as a result of a car collision, sports injury, biking incident, or car-pedestrian collision, to mention a few causes. Traumatic brain injury in childhood is the most prevalent cause of death and long term disability in children and affects all socioeconomic levels.

We now have evidence regarding two phases of brain recovery in childhood, an immediate phase and a latent phase.

For the purposes of this paper, we define the immediate phase as the time from the injury up to approximately one year post 10 BRAIN INJURY PROFESSIONAL

injury. We propose that the latent phase lasts from one year after injury to years after the injury, perhaps up to young adulthood. Fortunately at the immediate phase, tremendous gains in emergency medical treatment have increased chances of survival from even the most severe brain injuries. Intensive and state-of-the-art rehabilitation during the immediate phase is associated with marked improvements in cognitive, motor and social performance in children. Furthermore, consistent evidence indicates that the younger the child is that incurs the brain injury the better their prognosis is during this immediate phase. Because the doctors and family typically observe dramatic levels of recovery in childhood, the family often leaves the hospital or rehabilitation center fully expecting the child to have a complete or almost complete recovery and to return to the same level of functioning as before the injury.

The tenet of greater recoverability in youth has been held as fact and taught in medical school and rehabilitation classes on neurobiological mechanisms of repair as a guiding principle for predicting recovery from brain injury in children for decades.

Unfortunately, new evidence reveals that this tenet may be misleading and fail to account for the full impact of an injury on a developing brain during the latent phase of recovery.

Purpose The focus of this article is to bring to the public forefront new evidence regarding developmental patterns that need to be watched during the second consequential phase of recovery in pediatric brain injury. In particular, children who suffer a severe brain injury may be at risk for later emerging problems which we refer to as a neurocognitive stall. This stall, as defined below, may arise during the latent phase of recovery. fIGURe 1

Pediatric TBI: Two Stages of Recovery nt evelopme

Performance

Normal D

Neurocognitive Stall Latent Stage

Brain Injury Immediate Stage

Growing Up

Neurocognitive Stall Definition. We propose that children who suffer a severe brain injury may be at risk for manifesting a neurocognitive stall during the second phase of brain recovery. This neurocognitive stall is illustrated in Figure 1. We define “neurocognitive stall” as a halting or slowing in later stages of cognitive, social, and motor development beyond a year after brain injury. Despite remarkable recovery during the first year after severe brain injury, children may appear to “hit a wall” or “fail to thrive” in terms of their continued cognitive growth. It is not so much that they lose already acquired skills as it is a failure or lag in development of later emerging cognitive milestones. The neurocognitive stall may emerge despite seeming to have recovered cognitive abilities commensurate to their pre-injury level.

Evidence for Neurocognitive Stall Although not all children suffering a brain injury will exhibit a stall, recovery of cognitive, social and motor abilities in childhood is oftentimes not a one-time phenomenon. That is, when a brain injury occurs in childhood, the level of recovery or the impact of the injury is not fully known within the first year after injury (Reilly, Bates, and Marchman, 1998). In an analogous situation, consider that we cannot know if a child at 3 is going to be able to ride a bicycle at 6 years of age. We will discuss three key questions in this article to help elucidate neurocognitive stall in pediatric brain injury: 1. What cognitive areas show a developmental stall?

2. When is a neurocognitive stall most likely to emerge?

3. Who is at greatest risk for manifesting a neurocognitive stall?

What Cognitive areas show stall?

The general findings regarding the areas to consider as at risk for later emerging neurocognitive stall consistently support two major points. First, traditional measures of cognition and language typically lack sufficient sensitivity to consistently and reliably detect problems that emerge at later stages after severe brain injury in childhood. Traditional measures include achievement tests and structured measures of intellectual functioning and language competence, such as vocabulary and grammatical skills. Ewing-Cobbs and colleagues (1998) reported normal range achievement test scores in children two years post injury who had, in fact, failed a grade and required special education. Chapman and colleagues (1997, 2004) found measures of vocabulary and syntactical complexity to be within normal limits even after severe injury despite significant problems on measures of higher levels of language skills, e.g. discourse ability.

The second key point is that measures assessing frontal lobe abilities, such as summarizing information, selective learning (learning high value and inhibiting low value words), working memory, behavior control, inhibition, and problem solving, offer promising measures for identifying a neurocognitive stall. For example, one pattern that continues to emerge in children who have suffered a severe brain injury is the recovery of the ability to retell isolated details of a story. However, the majority of this population shows deficits in abstracting the central meaning of a message (Chapman et al., 1999, 2004, 2006). Precisely, this population recovered the ability to give back information either verbatim or close paraphrase – but showed a neurocognitive stall in the ability to summarize the key message of a passage, sometimes referred to as “gist”. One of the most fundamental abilities tied to academic performance is the ability to sift through massive amounts of incoming information to derive the gist. For instance, Hanten et al (2002,2004) found that children with severe brain injury were significantly impaired in selecting important information and inhibiting less important information, despite similar levels of memory capacity. In a similar vein, Levin and colleagues (2004) found that working memory fails to expand and even declines between 12 and 24 months post injury. Furthermore, Max and colleagues (2006) found later emergence of psychiatric problems associated with frontal lobe dysfunction at later stages post injury. With regard to motor skills, recovery in the pediatric population with a severe brain injury was found to be associated with lower written language abilities. This suggests that the more complex motor systems, such as the ones required in writing, may show a stall despite seemingly good recovery of gross motor skills (Chapman et al., in process; Cook, Chapman, & Gamino, in press).

When is a neurocognitive stall likely to emerge?

One hypothesis we have proposed is that children with severe brain injury may grow into their deficits and show a neurocognitive stall during adolescence. Why would we propose this to be a stage of increased risk of slowed or halted cognitive matuBRAIN INJURY PROFESSIONAL

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ration? Growing evidence reveals that the complex networks mental stages. In summary, emerging evidence indicates that of the frontal lobe show a protracted rate of development with the more severe the injury, the greater the child’s risk for neurapid growth from age 13 up to age 25 years. Shearing of rocognitive stalls at later stages post injury. Nonetheless, it is white matter, a common occurrence in brain injury, may dis- also imperative to recognize that in many cases, later deficits rupt the long-term brain maturation process of the frontal- never emerge.

Lesion variables. Preliminary evidence suggests that chilstriatal-temporal-cerebellum neural networks in the developdren who sustain injuries to the frontal lobe and to subcortical ing brain. Therefore, a neurocognitive stall may appear more evident when the functions of this complex neural network are areas are more likely to show neurocognitive stall. Specifically, Anderson and colleagues (1999) proposed that early frontal first emerging during and after adolescence.

Another possible explanation we have posited for neuro- lesions may be associated with later stage behavioral deficits.

As discussed above, slowed develcognitive stall around adolescence is that children with severe brain At this latent stage post injury, the trav- opment or latent deficits in behavmay emerge only at later ages injury may work hard to compenesty is that no link is made between later ior of brain maturation and cognitive sate for initial deficits in lower level skills, such as immediate memory. emerging cognitive problems, i.e. neuro- development.

Environmental and Genetic Therefore, they may strengthen cognitive stall, and a brain injury which the neural network supporting this occurred two, five or even ten years earlier. Factors. As new evidence abounds about the risk of neurocognitive skill. At the same time the neural networks mediating more complex cognitive functions (e.g. stall, studies are beginning to address the role of environment working memory, gist abilities), most of which show consid- and genetic risk factors. Clearly other factors including enerable maturation during adolescence, may either lag behind vironment and genetics could play a key role in predicting in recovery, become weakened, or fail to develop (Chapman, who will or will not manifest latent effects of an earlier brain injury. The nature of this relationship is only in the infancy of Gamino, et al., 2006). investigation.

Who is at risk?

The uncertainty in long term recovery and later stage cogni- Implications tive development is determined largely by four factors: (1) At this latent stage post injury, the travesty is that no link is the severity of the injury, (2) the locus of brain injury, (3) made between later emerging cognitive problems, i.e. neuroenvironmental support, and (4) genetic factors (an area in the cognitive stall, and a brain injury which occurred two, five or beginning stages of research). even ten years earlier. This failure to make the connection is Severity. Present evidence reveals that recovery and con- due to lack of knowledge regarding: tinued ability to reach later cognitive milestones is favorable in children with mild to moderate brain injuries. Nonetheless, 1. brain-behavior deficits at late stages post injury, some children with these milder forms of brain injury certain- 2. recommended practices on sensitive assessment protocols, ly may manifest a neurocognitive stall (Chapman, Gamino et 3. follow up assessment intervals such as used for pediatric al, 2006). The greatest risk of neurocognitive stall is for chilcancer in remission and dren who suffer a severe brain injury. Evidence reveals that 4. appropriate intervention methods to enhance brain repair these children may show slowed development at later cognior perhaps even prevent deficits from appearing at later tive stages or even failure to achieve more complex cognitive developmental stages. levels – suggesting that each new stage of cognitive development may need some form of follow up years after the injury Until recently, little was known about this latent phase (Chapman, McKinnon, et al, 2001). As Dennis (2000) warns, because few investigations followed children who suffered a time following a brain injury does not always translate to con- brain injury longitudinally for years to watch later developtinued recovery in developing children. mental stages. Therefore, problems during this latent phase Ewing-Cobbs and colleagues (2003) have proposed that have typically gone unrecognized and therefore untreated. recovery from severe brain injury may be limited to the skills One parent of a brain injured child who was a physician somthat were already established at the time of injury. Recovery berly remarked: of previously acquired skills, however, may not necessarily insure continued development of new and later emerging skills “Treatment seems backwards. We were surrounded by help or skills in a rapid state of development at the time of injury when the brain was undergoing spontaneous recovery. There (Chapman, McKinnon, et al, 2001; Chapman et al., 2004; was no help when we and our child’s brain needed treatment Ewing-Cobbs, Barnes, & Fletcher, 2003). A word of caution the most”. is needed here so that we do not overestimate the long term Although considerably more research needs to elucidate impact of severe brain injury, since many of these children do indeed achieve normal levels of cognition at later develop- the paradox of a neurocognitive stall in children with brain 12 BRAIN INJURY PROFESSIONAL

injury despite relatively good early recovery, it is clear that this information needs to be translated to practice now – to help these children. One key question is: Can timely intervention prevent the stall and encourage continued cognitive development? In brain injury, it remains difficult to predict which children will recover and continue to reach cognitive milestones and which ones will stall at later stages. However, much like children with forms of cancer such as leukemia, children with brain injury must be closely followed at periodic intervals with sensitive measures. Furthermore, they should be treated as soon as a “neurocognitive stall” is detected to insure they “stay in remission”. Rapid advances in neuroscience and functional brain imaging are beginning to allow us to study whether intense and timely treatment can prevent later reoccurrence of cognitive impairments – i.e. neurocognitive stall after brain injury in children. In the next decade, advances in (a) follow along protocols, (b) sensitive assessments, (c) short term intervals of intensive intervention, and (d) imaging to reveal the absence or presence of changes in the brain could bring tremendous gains to functional outcomes during the latent phase of brain recovery.

About the Author

Dr. Sandra Bond Chapman is the Director of the Center for BrainHealth® and is the Focus Group Head of Diseases of the Aging Brain for the Institute of Biomedical Sciences and Technology at The University of Texas at Dallas. Contact schapman@utdallas.edu.

References Anderson V.A. Catroppa C. Morse S.A. Haritou F, Functional memory skills following traumatic brain injury in young children. Pediatric Rehabilitation, 3 (4): 159 – 66, 1999.

Chapman S.B. Gamino J.F. Cook L.G. et al., Impaired discourse gist and working memory in children after brain injury. Brain and Language, 97: 178 – 188, 2006.

Chapman S. B. Levin H. S. Lawyer S. L, Communication problems resulting from brain injury in children: Special issues of assessment and management. Communication disorders following traumatic brain injury, 235-270, 1999.

Chapman S. B. McKinnon L. Levin H. S. et al., Longitudinal outcome of verbal discourse in children with traumatic brain injury: Three-year follow-up. Journal of Head Trauma Rehabilitation, 16: 441 – 445, 2001.

Chapman S. B. Cook L. G. Sparks G. et al., Recovery of written discourse after pediatric closed head injury. (in process).

Chapman S. B. Sparks G. Levin H. S. et al., Discourse macrolevel processing after severe pediatric traumatic brain injury. Developmental Neuropsychology, 25: 37-61, 2004.

Chapman S. B. Watkins R. Gustafson C. et al., Narrative discourse in children with closed head injury, children with language impairment and typically developing children. American Journal of Speech-Language Pathology, 6: 66-76, 1997.

Cook L. G. Chapman S. B. Gamino J. F: Impaired discourse gist in pediatric brain Injury: missing the forest for the trees. In: Cognitive Bases of Children’s Language Comprehension Difficulties. K. Cain and J. Oakhill (Eds.) Guilford Publications Inc., New York, New York. In Press.

Dennis M. Barnes M.A, Speech acts after mild or severe head injury. Aphasiology, 14: 391 – 405, 2000.

Ewing-Cobbs L. Barnes M. A. Fletcher J. M, Early brain injury in children: Development and reorganization of cognitive function. Developmental Neuropsychology, 24: 669-704, 2003.

Ewing-Cobbs L. Fletcher J. M. Levin H. S. et al., Academic achievement and academic placement following traumatic brain injury in children and adolescents: A two-year longitudinal study. Journal of Clinical and Experimental Neuropsychology, 20: 769-781, 1998.

Hanten G. Chapman S. B. Gamino J. F. et al., Verbal selective learning after traumatic brain injury in children. Annals of Neurology, 56: 847-853, 2004.

Hanten G. Zhang L. Levin H. S, Selective learning in children after traumatic brain injury: A preliminary study. Child Neuropsychology, 8: 107-120, 2002.

Levin H.S. Hanten G. Zhang L. et al., Changes in working memory after traumatic brain injury in children. Neuropsychology, 18 (2): 240 – 247, 2004.

Max J.E. Levin H.S. Schachar R.J. et al., Predictors of personality change due to traumatic brain injury in children and adolescents six to twenty-four months after injury. The Journal of Neuropsychiatry and Clinical Neurosciences, 18 (1): 21 – 32, 2006.

Reilly J. S. Bates E. A. Marchman V. A, Narrative discourse in children with early focal brain injury.

Brain and Language, 51: 335-375, 1998.

BRAIN INJURY PROFESSIONAL

13

Research Update: The Child and Adolescent Scale of Participation

by Gary Bedell, PhD, OTR

Participation in home, school, and community activities enables children to learn how to interact, work and live with others. However, children with acquired brain injuries and other disabilities often are restricted in their participation. Greater extent of participation has been linked to enhanced quality of life and reduction in health and social risk factors for children with and without disabilities. Promoting participation is a primary goal of rehabilitation, yet there is a lack of available measures to assess children’s participation.

The Child and Adolescent Scale of Participation (CASP) was initially designed as part of a follow-up survey to monitor outcomes and needs of children with acquired brain injuries (ABI) after inpatient rehabilitation. It measures extent to which children and youth participate in home, school, and community activities in comparison to children of the same age as reported by family caregivers. Initial psychometric testing has demonstrated evidence of test-retest reliability, internal consistency, and validity.

Further development and testing of the CASP is underway.

Thus far, data have been collected on approximately 250 children and youth with and without disabilities. Children with ABI comprise the largest group (n=111). Preliminary findings are similar to results obtained with the original sample of children with ABI. Children are demonstrating most restrictions participating in social leisure activities with peers, instrumental activities of daily living (e.g., household activities, managing daily schedule), and structured events in the community (e.g., team sports, attending concerts or holiday events). Children are demonstrating least restrictions participating in simpler routine movement, communication and self-care activities at home and school. Also, children with greater extent of cognitive, psychological and physical impairment, and with greater extent of physical and social environmental barriers reported are showing lesser extent of ageexpected participation.

The CASP might assist at the individual consumer level to identify where efforts are needed for providing services to an individual child and family. At a program and policy level, the CASP might assist with identifying which aspects of participation require more resources and where greater efforts are needed for specific diagnostic groups of children. Further research is needed to assess how responsive the CASP is for monitoring change over time at all levels of practice since this has not yet been studied.

It is expected that continued efforts to systematically assess and monitor children’s participation using diverse methods (e.g., selfreport, observation) that incorporate multiple perspectives (i.e., family caregivers, professionals and children) will provide useful information to assist with efforts to promote children’s participation and overall health and functioning across the lifespan.

About the Author

Dr Bedell’s research involves developing and evaluating measures and intervention strategies that address participation of children with disabilities and supports and barriers to their participation. Contact for further information: gary.bedell@tufts.edu

14 BRAIN INJURY PROFESSIONAL

Lash & Associates Publishing/Training Inc.

Visit our website at www.lapublishing.com for Information and Resources on Brain Injury and Concussion in Children and Adults Lash & Associates Publishing/Training Inc. provides practical, user friendly information for families, individiuals, clinicians, therapists, and educators that is based on the latest research and best clinical practices in acquired brain injury. Our authors are leading experts in the field. What’s different about us?

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Visit our Web site at www.lapublishing.com for a free catalog BRAIN INJURY PROFESSIONAL

15

A Holistic Approach for Improving Educational Outcomes of Students with TBI: Promising practices and new directions for research

by Ann Glang, PhD and Marilyn Lash, MSW Acknowledgements Special thanks for the leadership and comments of the Group on School, Transition, Intervention, and Education Issues at the Galveston Brain Injury Conference. In addition to the authors, this group included Charles Christiansen, EdD; Jean Dise-Lewis, PhD; Jeffrey Max, MD; Gary Seale, MS; Janet Tyler, PhD; and Jamie Williams, MEd. Introduction Although there is a growing body of research on the incidence, acute care and rehabilitation of children with traumatic brain injuries (TBI), this progress has not been met by similar gains in psychosocial and educational research on students with TBI. Despite the emergence of some promising practices and innovative research examining the impact of childhood injuries on families and the educational needs of students in the classroom, this population continues to be under-identified and under-served.

The challenge of addressing the latent developmental effects of childhood brain injuries is compounded by the fact that families often must assume the primary caregiving role and schools often become the sole providers of rehabilitation services. Neither families nor educators have been systematically prepared or trained for this role, despite the inclusion of traumatic brain injury as a category under the Individuals with Disabilities Education Act in 1991.

This article presents a holistic model for further research and program development to address the educational needs of students with TBI. The model draws heavily on two recent articles describing the needs of children with TBI and their families (Ylvisaker et al., 2001; Ylvisaker et al., 2005), and includes four themes with suggestions for innovative approaches to improving educational outcomes for this population.

1. Family training that recognizes families (usually parents) as the primary caregivers, case managers, advocates and educa16 BRAIN INJURY PROFESSIONAL

tional supports for the child.

2. Instructional strategies that incorporate educational research for students with other disabilities who have similar functional challenges.

3. Cost effective, efficient and systemic approaches to improve capacity within schools to identify and meet the needs of students with TBI. 4. A dynamic model for communication between parents and educators that increases the knowledge and advocacy skills of families to improve educational outcomes.

Theme 1: Develop innovative approaches to family training The negative impact of childhood traumatic brain injury on family functioning has been well documented (Hawley, Ward, Magnay, & Long, 2003; Verhaeghe, Defloor, & Grypdonck, 2005; Wade, Wolfe, & Pestian, 2004). Childhood TBI creates significant stress for parents and families during the first year post-injury (Max, Castillo, Robin, Mattheis, & Stierwalt, 1998; Rivara et al., 1996; Wade, Taylor, Drotar, Stancin & Yeates, 1998; Wade et al., 2002), and prospective studies have documented continued dysfunction in families of children with severe TBI three or more years post injury (Wade, Michaud, & Brown, 2006). A persistent theme expressed by families over time is the wide range of needs following hospitalization for childhood TBI including more information regarding the child’s injury and possible long-term outcomes; access to resources; (Aitken, Mele, & Barrett, 2004; Hawley, Ward, Magnay, & Long, 2002; Marks, Sliwinski, & Gordon, 1993; Wade, Taylor, Drotar, Stancin, & Yeates, 1996), and support/communication from others involved with the child (Aitken et al., 2004).

To help families support their child with TBI, a model of support is needed that includes the following five components: 1. information to build a knowledge base about childhood TBI

2. home based training in strategies for managing a child’s cognitive, behavioral, and physical challenges 3. advocacy skills for negotiating special education or 504 accommodations at school 4. coping methods and support for grieving and caregiver stress 5. “case management” skills that prepare the parent/family member as the service manager over the child’s education and development.

Recent research findings are available in two of these areas home based rehabilitation training and advocacy skills. Braga, Campos da Paz, & Ylvisaker (2005) demonstrated that children whose families used cognitive and physical interventions in the home showed significantly greater improvements one year later than did children who received rehabilitation in a rehabilitation facility. Similarly, parents who used a web-based intervention offering training and support for families with children with TBI reported a reduction in problem behaviors, increased knowledge, and participant satisfaction with the technology and therapeutic relationship (Wade, Wolfe, Brown, and Pestian, 2005). There is also evidence to suggest that parents can acquire skills for educational advocacy through targeted training to help them be more effective partners in educational planning and problem solving (Glang, McLaughlin & Schroeder, in press).

These promising areas of work recognize the central role of families in the child’s development and the critical linkage they provide with educators and other community-based professionals. Most importantly, such research has the potential to prepare families to recognize the latent developmental effects of childhood TBI which often are misidentified as symptoms of learning disability, ADHD or emotional disorders.

Theme 2: Examine the efficacy of instructional strategies validated with other populations Historically, the field of childhood TBI has emphasized its unique learning and behavioral impact and called for differential instructional approaches for this population. However, the wide variability within this population argues against the use of any TBI-specific curriculum or assessment (Ylvisaker et al., 2001). Further, there have been few empirical studies evaluating specific educational interventions or management practices for students with TBI. Fortunately, there is a substantial body of research on effective instructional and behavioral strategies for students with other disabilities, but with similar functional challenges.

When students with TBI are identified by functional need (i.e. problems with attention, memory, impulse control, etc.) rather than by the diagnosis of TBI, a large body of educational research can be applied. For example, cognitive behavior modification strategies validated with adolescents with disinhibited and potentially aggressive behavior (Robinson, Smith Miller & Brownel, 1999) may be effective with students with TBI exhibiting similar challenges, and many of the instructional strategies validated with students with learning disabilities (e.g., Pressley et al., 1995) show promise with students with TBI who have challenges with new learning and memory.

Applying strategies that are effective with students with similar functional challenges recognizes the strengths and skills of educators and builds upon those skills rather than devaluing the educator’s experience with other student populations. In contrast, setting up TBI as a medically based disability requiring special teaching techniques may set up oppositional expectations and

conflicts between families and educators, schools and rehabilitation providers.

Theme 3: Build the capacity of the educational system to support students with TBI Although special education training addresses the academic, behavioral, and social needs of children with other types of disabling conditions, the unique and complex constellation of issues presented by each child with TBI challenges the skills and experience of many special educators (Ylvisaker et al., 2001; Glang & Todis, 1997). Inadequate understanding of the cognitive and behavioral deficits associated with TBI by teachers and staff has been shown to be an obstacle to positive school re-entry (Vaidya, 2002) and to the provision of appropriate supports for children with TBI. Traditional approaches to improving this situation do not hold much promise. Research in teacher training suggests that the typical approach to staff development--“one-shot” in-service without follow-up—is ineffective in facilitating transfer to the classroom (Gersten, Carnine, Zoref, & Cronin, 1986; Sparks, 1983). Teachers need situation- and context-specific help to help them use new strategies and skills in the instructional setting (Glang, Gersten, & Morvant, 1994; Lewis & Newcomer, 2002; Ylvisaker, Feeney, & Urbanczyk, 1993, Ylvisaker et al., 2001).

Findings from recent work in teacher training in childhood TBI suggest that providing comprehensive training for educators in TBI results in improved capacity within the educational system (Davis, 2004). In a number of states, Departments of Education have implemented a TBI Consulting Team model, which provides training and support to interdisciplinary teams who offer in-service training and ongoing consultation to local schools (Glang, Tyler, Pearson, Todis, & Morvant, 2004). Following implementation of the TBI Consulting Team model in southern Arizona (N = 100 educators), identification rates of students with TBI for special education services increased three-fold, from 93 in 19992000, prior to the training effort, to 319 in 2002-2003, after the training occurred (Glang et al., 2006). These findings suggest that increased awareness and knowledge of disability characteristics may impact identification rates by school personnel.

Just as there is much to be learned from educational strategies with other student populations, it is important that specialists and researchers in TBI learn how to integrate TBI services within educational systems by collaborating with other disability advocates and educational policy makers. The gains made by parents of children with other disabilities can serve as models for building resources and capacity with the educational system for students with TBI. Theme 4: Support parents as educational advocates Parents of students with TBI are often unprepared to support their child in the school re-entry process because prior to the injury, their child progressed typically through school. They may not have a full understanding of the impact of TBI on school performance and are likely unfamiliar with the provisions of IDEA and their rights in the educational process (Martin, 1988).

Further, failure of the medical community to recognize the impact of a TBI on the child’s education and to assist families in this transition to special education is evident in the low referral rate of students for special education services. A National Pediatric Trauma Registry study that tracked children ages 5-19 who were hospitalized with TBI between April 1994 and January 1999 found that although 13.2% had documented cognitive impairments resulting from their brain injury at the time of discharge, and 11.6% had behavioral impairments; medical staff BRAIN INJURY PROFESSIONAL

17

recommended less than 1% of these children for referral to special education (DiScala, 2000). Further, if a child is not admitted to a pediatric rehabilitation program upon discharge from acute care, the family will not benefit from the hospital to school transition programs designed to prepare the child and the school for the student’s return to the classroom (DePompei, Blosser, Savage, & Lash, 1998).

Because educators have minimal understanding of TBI (Walker, Boling, & Cobb, 1999), parents often find themselves in the position of providing information to staff at their child’s school.

Many parents need assistance communicating with school personnel about the nature and consequences of brain injury (Wade, Carey, & Wolfe, in press) and with accessing supports at school (Wade, Michaud, & Brown, 2006). Findings from studies with parents of children with other disabilities suggest that parents can acquire skills to advocate more effectively for their children (DePompei & Blosser, 1999; Martin, 1988). A recent randomized trial examined the efficacy of training similar to that used with parents of children with other disabilities to improve parental advocacy skills (Glang et al., in press). Participants in the treatment group who used a web-based training program demonstrated significant improvement in understanding and discriminating the key communication skills in typical parent-teacher interactions.

The skills learned by parents participating in this preliminary study may translate to decreased confrontation and more effective, focused meetings between parents and educators.

Many state Brain Injury Associations have developed peer outreach/mentor programs that link experienced family members with those just experiencing the trauma of brain injury. Shown to be an effective model for education and support (Hibbard, Cantor, & Charatz, 2002), this concept could readily be adapted for families with school age children. In addition, a national network of Parent Training and Information Centers (www.taalliance.org) has resources to help families of children with special needs become effective advocates for special educational services.

Conclusion These four themes present a holistic approach to future research that recognizes the central role of families, that expands upon educational research with other school age populations, that proposes a systems approach to developing capacity and services within schools, and that recognizes the importance of mentors for effective advocacy. Families and educators are the central and critical entities in the child’s development, education and preparation for adulthood. It is imperative that future research address the capacity of families and educators to function as collaborators rather than adversaries in the child’s education. More needs to be understood about the efficacy and adaptation of instructional strategies used with other populations for students with TBI. Only by shifting to models for systems development will researchers help schools build their capacity to fully address the needs of students with TBI and to include families in this process.

About the AuthorS

Dr. Glang is an Associate Research Professor at TRI and is Principal Investigator of a longitudinal study of educational outcomes of children and youth with TBI. She has developed and evaluated a range of training tools on TBI for parents and teachers.

Marilyn Lash is a founding partner of Lash and Associates Publishing/ Training, Inc. with a special interest in the psychosocial and educational impact of childhood injuries. She is author of numerous publications for families, educators and clinicians.

18 BRAIN INJURY PROFESSIONAL

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DePompei R, Blosser JL. Managing transitions for education. In: Rosenthal M, Griffith ER, Kreutzer JS, Pentland B, eds. Rehabilitation of the adult and child with traumatic brain injury 3rd ed. Philadelphia, PA: F. A. Davis; 1999:393-409.

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Max JE, Castillo CS, Robin DA, Mattheis PJ, Stierwalt JAG. Predictors of family functioning following traumatic brain injury in children and adolescents. Journal of the American Academy of Child Adolescent Psychiatry. 1998;37:83-90.

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Ylvisaker M, Feeney T J, Urbanczyk B. Developing a positive communication culture for rehabilitation: Communication training for staff and family members. In CJ Durgin, ND Schmidt, LJ Fryer, Eds. Staff Development and Clinical Intervention in Brian Injury Rehabilitation (pp. 57-85). Gaithersburg, MD: Aspen. 1993.

professional appointments RN PATIENT CARE DIRECTOR for three Rehabilitation nursing units including brain injury, spinal cord injury , stroke and pain management. Touro Rehabilitation, New Orleans, LA. Minimum 5 years experience. MSN required. Apply online at www.touro.com.

PT, OT, ST for Per-diem positions, STAFF DEVELOPMENT COORDINATOR-F/T, REGISTERED NURSES openings at Craig Hospital. For information go to www.craighospital. org. Career Opportunities, or send resume to Susi Szaltzer, RN, BSN, MS, Healthcare Recruiter, Human Resources, Craig Hospital, 3425 South Clarkson Street, Englewood, CO 80113. Phone: (303) 789-8463, Fax: (303) 789-8684 or Sszaltzer@craighospital.org.

RNs Touro Rehabilitation Center is seeking RNs full time, part time, and flex for their 27 bed Physical Rehab Unit for Stroke and SCI patients who need bedside rehab nursing caregivers. Prefer Certified Rehabilitation Registered Nurses, 8 and 12 hour shifts, with weekendonly options available. Competitive salary. Contact Susan Greco at GrecoS@Touro.com or phone (504) 897-8082 to apply.

STAFF OTs Touro Rehab Center is seeking staff OTs for inpatient and outpatient programs.

Experience preferred. To apply, contact Marylee Pontillas at (504) 897-8309 or by email at PontillasM@Touro.com.

NURSES needed for brain injury rehab at Centre for Neuro Skills, a post-acute brain injury rehab clinic which offers intensive residential and out-pt rehab for clients recovering from all types of acquired brain injury. The CNS community based approach focuses on helping clients regain a normal rhythm of living. Irving, TX clinic has openings for Licensed Nurses, M-F, holidays off, exc. benefits. Rehab experience is preferred. Resumes to hrtx@neuroskills.com or call (972) 580-8500.

DIRECTOR, THERAPY SERVICES for premier facility: 124 bed state-of-the-art hospital that provides comprehensive medical rehabilitation programs for people with spinal cord124bed, state-ofthe-art hospital that provides comprehensive medical rehabilitation programs for people with spinal cord and brain injuries, stroke and other neurological and orthopedic disorders. Only freestanding physical rehab center in the state, and one of only 17 hospitals in the country designated a Traumatic Brain Injury Model System. Located in Southeastern, capital city honored as one of America’s Most Livable Cities. Cost-of-living below national average, wide variety of reasonable housing options, public school systems with Level 5

state accreditation, 2 and 4-year colleges, and number of cultural and recreational activities.

Reports to VP. Department has 39 FTEs with little turnover. Require 10 years’ combined management and clinical experience in Therapy Services, Master’s and current licensure.

Strong management, communication and clinical skills, and proven leadership ability in planning, organization and working with and through others. Contact: Linda Garrett, Garrett Associates Inc., (404) 364-0001, Garrett@GAISearch.com.

OCCUPATIONAL THERAPIST - Opportunity to make a difference with clients who have sustained or acquired brain injuries. This individual will work with a team of skilled professionals. Related degree and license to practice is required. Contact Cynthia Calhoun, PHR, Director Human Resources at Transitional Learning Center, 1528 Postoffice Street, Galveston, TX 77550, (800) TLC-GROW or (409) 797-1445. Fax (409) 797-1480 or email: ccalhoun@tlc-galveston.org. www.tlcrehab.org.

OCCUPATIONAL THERAPIST Peace Rehabilitation Center, located in downtown Greenville, SC, specializes in community reintegration and provides unique opportunities for treatment. The Greenville Hospital System University Medical Center is one of the largest hospital systems in South Carolina and a leader in research, medical education and critical care.

We are seeking SC License or SC License eligible candidates for a full-time Occupational Therapist position. Experience preferred. CARF accredited Outpatient brain injury program.

We offer competitive pay, excellent benefits package, relocation assistance, 90 day COBRA Reimbursement and interview expenses. $5000 Sign on Bonus. Visit our website at www. ghs.org to learn more and submit an online application for immediate consideration. Contact Renee’ Bacon, Senior Employment Specialist, for more information at (864)455-8452.

Clinical Director of Acquired Brain Injury Services at The Children’s Trust, Tadworth, Surrey, UK. Responsibilities: directing and monitoring children’s therapeutic programs and goals; liaising with families and sharing good practice with the wider children’s arena; and promoting The Children’s Trust as the UK’s leading center for pediatric brain injury rehabilitation. Contact: Andrew Ross, Chief Executive. Telephone (UK) 01737 365044 or email andrewross@thechildrenstrust.org.uk.

To list your professional appointments on this page, please contact Joyce Parker, (713) 526-6900, or by e-mail: jparker@hdipub.com.

Specializing Solely in Post-Acute Brain Injury Rehab Since 1982

TLC is a nationally recognized pioneer in the field of post acute brain injury treatment and has provided world class care at competitive prices since 1982. TLC’s not-for-profit status allows us to be less focused on profits and more focused on client care and staff qualifications. We offer the full continuum of treatment modalities with a full time physician, nursing care and 6 hours per day of therapy provided by licensed and certified therapists. This intensity of care provided by highly skilled staff means we get clients home as quickly as possible with better outcomes. TLC also offers long term supported living at Tideway on Galveston Island – a program you must see to appreciate.

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BRAIN INJURY PROFESSIONAL

19

Outcomes and Assessment in Childhood Traumatic Brain Injury

by Keith Owen Yeates, PhD Acknowledgement: This paper represents the efforts of the entire Outcomes and Assessment workgroup, including Drs. Vicki Anderson, Gary Bedell, Margaret Brown, Gerard Gioia, Wayne Gordon, Jean Langlois, Ken Ottenbacher, Richard Temple, and Gale Whiteneck.

During the Galveston Brain Injury Conference in May 2006, one of the workgroups focused on outcomes and assessment in childhood traumatic brain injury (TBI). The workgroup’s charge was to take a broad perspective on the key outcomes of childhood TBI and to identify best practices in how they can and should be assessed. To set the stage for the workgroup’s discussion, Dr. Keith Yeates made a presentation to all conference participants that attempted to frame some of the relevant issues. He suggested that state-of-the-art approaches to outcomes and assessment would reflect several features: • they would be grounded in and guided by explicit conceptual models; • they would reflect multiple levels of analysis, including biological, psychological, and social components; • they would be time-referenced, reflecting the dynamic processes that occur over time following TBI; • they would be developmentally-referenced, reflecting the child’s age at injury and age at assessment; • they would reflect multiple frames of reference, in terms of the persons assessed, the contexts in which assessment occurred, and the methods used.

In the ensuing workgroup discussion, the participants agreed that the World Health Organization’s International Classifica20 BRAIN INJURY PROFESSIONAL

tion of Functioning, Disability, and Health (ICF; World Health Organization, 2001) provides a useful framework for conceptualizing outcomes of childhood TBI. The ICF, which is presented in schematic form in Figure 1, conceives of functioning and disability as involving multiple levels of analysis, including the basic health condition (including specific disease states), bodily structure and function at both physical and psychological levels, the performance of activities at a personal level, and participation at a community or societal level. The ICF also acknowledges that personal and environmental factors can act as contextual moderators of disability and functioning, operating either as positive or negative influences (Whiteneck, 2005).

The workgroup felt that one of the strengths of the ICF is its focus on activity and participation as critical outcomes, rather than being concerned solely with the basic health condition and impairments in bodily structure and function. In both research and clinical practice, the emphasis in childhood TBI has often been on how to measure the injury itself or specific aspects of cognitive or behavioral functioning. For example, the Glasgow Coma Scale provides a rapid means of assessing neurological status (Teasdale & Jennett, 1974), and neuropsychological testing yields a detailed portrayal of a child’s cognitive and behavioral functioning (Grewe & Yeates, 2005). In contrast, less attention has been paid to the ability to engage in meaningful functional activities or to participate in developmentally-appropriate roles in the larger community (Bedell, 2004).

Another strength of the ICF is its focus on both intact and impaired functioning. Previous models of disability have often focused primarily on children’s impairments and disabilities,

fIGURe 1

ICF model of disability

Personal factors

Structure & function Activity Participation

Environmental factors

Health condition

rather than presenting a balanced picture that also acknowledges their competencies and abilities. Because rehabilitative and educational efforts often capitalize on intact domains of functioning, as well as trying to remediate areas of impairment, it is critical to document positive as well as negative outcomes.

The ICF also was viewed positively by the workgroup because of its focus on contextual factors, both personal and environmental, as important determinants of outcome. Research has clearly demonstrated that the family and social environment is an important moderator of the outcomes of childhood TBI, as are the personal resources that children bring to bear when they are injured (Taylor et al., 2002; Yeates et al., 2005).

The ICF acknowledges the need to assess both kinds of contextual factors if we are to best predict the outcomes of childhood TBI, and in so doing also implies that such factors may be the focus of intervention to promote better outcomes.

One of the shortcomings of the ICF as a framework for understanding the outcomes of childhood TBI is that it is relatively static. The workgroup felt that a comprehensive model of outcomes needed to reflect the dynamic interplay between development and recovery that occurs after childhood TBI (Taylor& Alden, 1997). The specific outcomes that are of interest following TBI depend on the child’s developmental status both when injured and when outcomes are assessed, as well as on how much time has passed since the injury.

When the workgroup began to consider specific forms of assessment, the discussion was guided by several questions. The first was what outcomes to assess. The workgroup agreed that the outcomes to be assessed should reflect the breadth of the ICF, and therefore range from measures of the injury itself to measures of broader societal participation. Several workgroup members argued that the assessment of outcomes should incorporate both subjective and objective methods, particularly at the level of participation, where the child’s and family’s own perspective are critical. The workgroup noted that the ICF does not explicitly incorporate the construct of ‘quality of life’ (Whiteneck, 2005), but felt that the assessment of outcomes following childhood TBI should do so.

The next question the workgroup considered was why to assess certain outcomes. The workgroup discussed various goals.

Considerable conversation was devoted to the identification of children with TBI, especially those with milder injuries. The workgroup agreed that the outcomes of TBI cannot be assessed unless children who are injured can first be identified. The

workgroup reviewed a variety of approaches to the identification of children with TBI, in terms of instruments (e.g., Brain Injury Screening Questionnaire; Gordon, Brown, & Hibbard, 1997), sites (e.g., hospitals, schools), and implementers (e.g., trauma registrars, school nurses). The identification of children with TBI for the purposes of assessing incidence was differentiated from the identification of children in need of intervention (i.e., identifying who has a TBI vs. who needs help), and it was agreed that the two purposes may require distinct assessment strategies.

Another important consideration with regard to the goals of assessment was that it should be clinically relevant. The workgroup acknowledged that assessment tools that are useful for research purposes may not always be useful in clinical settings.

To be clinically meaningful, measures not only must have adequate age-based norms, but they should also be ecologically valid and sensitive to change, and ideally assist in guiding intervention (i.e., be prescriptive).

The next question to be discussed was when assessment should occur. The workgroup agreed that the assessment of outcomes should be an ongoing process that reflects the interplay between development and recovery that occurs after childhood TBI. The focus of assessment frequently varies as a function of time post-injury. For instance, the child’s basic health and bodily structure and function often receive the most attention during the acute phase shortly after a TBI, the capacity for functional activities usually is the focus of post-acute rehabilitation, and social participation may become of prime concern during community re-entry.

The workgroup also considered whose outcomes should be assessed, in terms of both the target of assessment and whose perspective is assessed. Although most discussions of outcomes focus on the children with TBI, we know that the effects of childhood TBI extend more broadly, to include parents, siblings, and extended family members (Wade et al., in press).

Moreover, the assessment of outcomes needs to take into the subjective perspectives of the child, as well as those of parents, teachers, and other important adults. Thus, the workgroup agreed that assessment of outcomes should extend across multiple targets, rather than being limited to the child with TBI, and also should take into account multiple frames of reference.

The workgroup also discussed where or in what contexts to assess outcomes. One of the shortcomings of many traditional outcome measures are that they are not collected in the child’s everyday environments and do not necessarily take into account how contextual factors affect children’s functioning. The workgroup agreed that the assessment of outcomes should occur across the multiple settings in which children are expected to function, including home and school, and should reflect the various interpersonal contexts in which children find themselves on a daily basis. The latter considerations are especially important when attempting to assess children’s functional activities and social participation. One of the obstacles to comprehensive assessment of outcomes following childhood TBI is the paucity of good models or measures for assessing the context itself (Whiteneck, 2005). The workgroup discussed available measures, including the Child and Adolescent Scale of the Environment (Bedell & Dumas, 2004).

BRAIN INJURY PROFESSIONAL

21

The last question the workgroup considered was how to assess outcome. The workgroup discussed the various methods available, ranging from traditional tests of cognitive functioning to rating scale measures to direct observations. They agreed that regardless of the methods used, the focus of assessment should be on the person being assessed rather than on the measures themselves, which are merely tools. The workgroup spent time discussing measures that are currently available for assessing the various components and levels of the ICF. They paid particular attention to measures developed since 2000, when an expert working group convened by the Centers of Disease Control reviewed the assessment of outcomes in childhood TBI (Langlois, 2000). The workgroup also discussed desirability and need for a minimal data set that could be collected on all children with TBI (Sherwin et al., 2006).

The final task of the workgroup was to consider potential projects that could be undertaken to consolidate and disseminate existing knowledge regarding best practices with regard to outcomes and assessment. One suggestion was to prepare a journal article that described current methods of assessment, using the ICF as a guiding framework. Other potential forums for dissemination of this information included professional meetings, established research networks, and scientific journals. The workgroup felt that more effort was needed to share information with practitioners, as opposed to the academic community.

Thus, another suggestion was to develop practitioners’ guides to outcomes and assessment that could be targeted to specific professional groups (e.g., pediatricians, emergency medicine physicians, school nurses, rehabilitation professionals).

LiveOakLiving.com

About The Author

Keith Owen Yeates, PhD, is a Professor in the Departments of Pediatrics, Psychology, and Psychiatry at The Ohio State University. In addition to being the Director of the Center for Biobehavioral Health in the Columbus Children’s Research Institute, he is the Chief of the Department of Psychology at Columbus Children’s Hospital.

REFERENCES

Bedell, G. M. (2004). Developing a follow-up survey focused on participation of children and youth with acquired brain injuries after discharge from inpatient hospitalization. NeuroRehabilitation, 19, 191-205.

Bedell, G. M., & Dumas H. M. (2004). Social participation of children and youth with acquired brain injuries discharged from inpatient rehabilitation: A follow-up study. Brain Injury, 18, 6582.

Gordon, W. A., Brown, M., & Hibbard, M. (1997). Brain injury screening questionnaire. New York: Mount Sinai School of Medicine; 1997.

Grewe, S. D., & Yeates, K. O. (2005). Neuropsychological assessment and the neuro­logically impaired child. In W. M. Klykylo & J. Kay (Eds.), Clinical Child Psychiatry (2nd ed., pp. 447-469).

Philadelphia: W. B. Saunders.

Langlois, J. A. (Ed.) (2000). Traumatic brain injury in the United States: Assessing outcomes in children. Atlanta: Centers for Disease Control and Prevention.

Sherwin, E., Whiteneck, G., Corrigan, J., Bedell, G., Brown, M., Abreu, B., Depompei, R., Gordon, W., & Kreutzer, J. (2006). Domains of a TBI minimal data set: Community reintegration phase. Brain Injury, 20, 383-389.

Taylor, H.G. & Alden, J. (1997). Age-related differences in outcomes following childhood brain insults: An introduction and overview. Journal of the International Neuropsychological Society, 3, 1-13.

Taylor, H. G., Yeates, K. O., Wade, S. L., Drotar, D., Stancin, T., & Minich, M. (2002). A prospective study of short- and long-term outcomes after traumatic brain injury in children: Behavior and achievement. Neuropsychology, 16, 15-27.

Teasdale, G., & Jennett, B. (1974). Assessment of coma and impaired consciousness: A practical scale. Lancet, 2, 81-84.

Wade, S. L., Taylor, H. G., Yeates, K. O., Drotar, D., Stancin, T., Minich, N. M., & Schluchter, M. (in press). Long-term parental and family adaptation following pediatric brain injury. Journal of Pediatric Psychology.

Whiteneck, G. (2005) Conceptual models of disability: Past, present, and future. In M. J. Field, A. M. Jerre, & L. Martin (Eds.), Workshop on disability: A new look (pp. 50-66). Washington: The National Academies Press.

World Health Organization. (2001). International classification of functioning, disability, and health.

Geneva, Switzerland: World Health Organization.

Yeates, K. O., Armstrong, K., Janusz, J., Taylor, H. G., Wade, S., Stancin, T., & Drotar, D. (2005).

Long-term attention problems in children with traumatic brain injury. Journal of the American Academy of Child and Adolescent Psychiatry, 44, 574-584.

22 BRAIN INJURY PROFESSIONAL

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Putting Lives In Motion for 21 Years

The University of Akron’s School of Speech-Language Pathology serves as principal investigator for a 1.5 million dollar project funded by the National Institute on Disability Rehabilitation Research (NIDRR). This project studies the use of PDAs with persons with cognitive challenges as a result of traumatic brain injury or intellectual disabilities. Partners in the project are Temple University’s Institute on Disabilities (adults with intellectual disabilities, Spaulding Rehabilitation Center (adults with traumatic brain injury) and the Brain Injury Association of America (dissemination).

The University of Akron is the site for study of students, age 8-21 with cognitive challenges and recently completed 35 device trials with students.

The project studied the benefit of PDAs to the memory and organization skills of students in schools and homes. Researchers measured on-time behavior of students under three conditions, a simple list of times and tasks, an appointment book, and two brands of PDAs. Students participated for two, 4-week periods, receiving one a.m. reminder “don’t forget your appointments today” during period 1 and no reminders during period 2. The results of comparing PDAs to simple lists was p < .024, and PDAs to appointment books, p< .002. Results of the study indicate that students benefited most from PDAs, next from simple lists, and least from appointment books.

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for its limited use. However, PDAs, a generic technology, have the potential of enhancing student independence at a relatively low cost; devices used in the study cost $250. When individuals can monitor their daily schedule with generic technology, the level of care and related costs can be reduced.

The research suggests that clinicians should consider low-cost, generic device before moving to specialized assistive technology.

Lower costs may draw support from agencies, schools, and society because of the rising cost of health care. Clinicians should also consider the appeal of generic technology when considering memory supports, because students may accept a PDA more readily if the device is the norm. Cell phones are currently the “generic technology of choice”. So, for example, when students own or use cell phones they may already understand the technology and only require intervention with the PDA functions in smartphones, which merge cell phone and PDA functions. The data from this project suggest that PDAs hold promise for enhancing prospective memory for school-age individuals, in a home or school environment.

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Neuroscientific Principles Underlying Reorganization After Brain Injury

by Cherie R. Percaccio, Phd and Michael P. Kilgard, Phd Research Summary Animal models of plasticity permit a detailed level of analysis of the neurochemical, structural, and physiological factors of brain reorganization that are not possible in humans. Since abnormal responses to sensory stimuli interfere with the brainâ&#x20AC;&#x2122;s ability to develop and learn properly, our research focuses on understanding how the brain adapts to the changing needs of the environment. We have documented the consequences of housing in enriched environments (inclusive of social, physical, and sensory stimulation) on auditory evoked potentials compared to those of rats housed in an isolated, boring environment (Engineer et al., 2004; Percaccio et al., 2005). We learned several things about how experience contributes to brain development, including that enrichment rapidly (within 2 weeks) and robustly (3-fold) increases the brainâ&#x20AC;&#x2122;s response to sensory stimuli in both young and adult rats (Figure 1).

However, the brain responds just as rapidly to the negative effects that result from a lack of stimulation. The ultimate goal of our research is to learn how to direct the brainâ&#x20AC;&#x2122;s innate ability to remodel sensory networks to help individuals recover lost skills and develop new ones.

Introduction Since the brain is composed of 100 billion cells with more than a hundred trillion connections, the consequences of damage are likely to be widespread and unique. Given that there may be more than 1 million pediatric head injuries this year and tens of thousands of children with life-long disabilities as a result (Brain Injury Resource Foundation, 2006), understanding how to manipulate neuronal repair and regeneration is critical to tailor therapies appropriate to each individual. The location and timing of an injury determine the degree to which cog26 BRAIN INJURY PROFESSIONAL

nitive, language, social, sensory, and motor skills are affected.

Conventional forms of therapy, including speech, occupational and physical therapy, may be effective because they enhance the amount and type of experience with the affected modality. Although experience changes brain organization throughout the life span, a permissive environment, including injury-induced neurogenesis (Ramaswamy et al., 2005; Itoh et al., 2005), may exist for up to several months after injury during which these types of experiences can enhance cortical reorganization (Dash et al., 2001; Kernie et al., 2001).

Stages of Injury Best practice in the treatment of brain injury seems to be to enhance neuroprotection in the acute phase of injury and plasticity during the chronic phase of injury (reviewed in Stein and Hoffman, 2003). Inhibitory pharmacological agents administered during the early post-injury period lessen the impact of the trauma on adjacent tissue (reviewed in Marklund et al., 2006), so it will be available for reorganization (Carmichael and Chesselet, 2002). Excitation at this time will cause excessive neurotransmitter release that is toxic to neurons (Humm et al., 1999). For example, forced use of the impaired limb early after a motor cortex lesion increases the size of the lesion and impairs functional recovery (Humm et al., 1998), whereas at later periods, constraint-induced movement therapy increases the area of cortex responsive to stimulation of the impaired limb (Friel et al., 2000). These results indicate that excitation is better suited for the chronic stages of recovery. Behavioral therapies are the best choice with which to enhance neurogenesis and stimulate reorganization. Pharmacological agents may also have a place in the chronic stage of recovery (Goldstein, 2003), but should be used with caution in pediatric populations. They

Figure 1 Young enriched rats, standard housed as adults Standard housed young rats, enriched as adults

A) After 1 week of differential housing, the grand mean average auditory evoked potentials of enriched and standard-housed rats were indistinguishable. B) After 2 weeks of differential housing, responses of young rats in the enriched environment were larger than responses from rats in the standard environment. C) By 5 weeks of differential housing, responses of young enriched rats were three times the amplitude of standard-housed rats.

D) After moving to the enriched environment, the responses of adult rats were larger than responses from rats in the standard environment. The gray shaded regions represent the standard error of the mean for each group.

can have uncertain effects on the developing nervous system, and may not be effective unless coupled with behavioral experience, anyway. For example, rats with motor cortex lesions whose movements are restricted during drug administration do not recover (Feeney et al., 1982). Moreover, in the absence of postinjury behavioral rehabilitation, the tissue surrounding the lesion continues to undergo degenerative changes (Nudo et al., 1996), related to the “use it or lose it” phenomenon.

Collectively, these results indicate that it is the right types of behavioral experiences that enhance sprouting and regeneration of damaged pathways.

Cortical Plasticity Sensory networks in the brains of animals and humans are continually remodeled to optimize goal-oriented behaviors based on environmental circumstances. Although occasionally, the cognitive, sensory, or motor impairments resulting from a brain injury gradually diminish, most often the individual develops compensatory behaviors to adapt to the deficit and accomplish the goal. For example, over 2 weeks, rats learn to use subtle compensatory strategies to successfully reach for food (Whishaw, 2000). After injury, behavioral compensation is possible because adjacent healthy tissue takes over the neurochemical and physiologic functions of the damaged tissue. Reorganization can be as extreme as the injury-induced takeover of visual cortex by auditory projections (Sur et al., 1988), but also includes more subtle forms, such as behavioral improvements resulting from meaningful practice (Jenkins et al., 1990; Recanzone et al. 1992a). Collectively, these results indicate that this innate ability to reorganize can be driven by experience. However, any beneficial form of reorganization requires appropriate experiences at the appropriate time to drive the growth of new synaptic connections that replace those lost after brain injury.

There may be dramatic individual differences in the “appropriateness” of experiences depending on the location and size of the lesion relative to pre-existing cortical receptive fields.

The location and size of pre-existing receptive fields depends on an individual’s history of experiences, and can be enhanced or degraded depending on environmental exposure or skill ac-

quisition (Xerri et al., 1998; Engineer et al., 2004). Hence, conventional forms of therapy may benefit one individual and either cause no change or be damaging to another (i.e., result in loss of cortical area and the formation of undesirable connections). Although, enriched environments and activities are beneficial for brain development at all ages (Engineer et al., 2004; Percaccio et al., 2005), and specifically, may aid in recovery after traumatic brain injury (Hamm et al., 1996), it may be more helpful to focus meaningful therapy on the specific modality affected by the injury (Biernaskie and Corbett, 2001). The basic principles of neuroscience research can help us determine, and understand why, certain forms of therapy are more appropriate than others for a unique individual with a unique brain injury.

Rehabilitation Since cortical reorganization determines recovery of function after a brain injury, rehabilitative therapy can be used to guide plasticity (reviewed in Nudo, 2003). Whereas these results suggest that practice with the affected modality expands the region of the cortex responsive to stimulation, meaningless repetition of drills, at best, does not encourage the desired regions of the cortex to expand. Rats that repeatedly ran on an exercise wheel did not have new connections in the brain (Kleim et al., 2002). Only rats that learn new skills have new connections in motor cortex (Kleim et al., 1998; Plautz et al., 2000).

At worst, repetition strengthens maladaptive cortical networks, resulting in undesirable behavioral sequel (i.e., Zandt et al., 2006) . Repeated sensory stimulation only alters cortical response properties when stimuli are used to make behavioral judgments (Recanzone et al., 1992b; Recanzone et al., 1993).

Several neuromodulators, including dopamine, norepinephrine, and acetylcholine, regulate cortical plasticity and learning, and are increased during motivated and attentive states (Gu, 2002). High levels of attention increase the firing rates and response synchronization of cortical neurons (i.e., neurons that fire together, wire together) (Steinmetz et al., 2000; Recanzone and Wurtz, 2000; Treue and Maunsell, 1999). Taken together, these results indicate that while manipulating sensory experiences to focus on the affected modality, clinicians can make BRAIN INJURY PROFESSIONAL

27

therapy activities fun to increase motivation and manageably difficult to increase attention.

Cholinergic Activity Nucleus basalis in the forebrain releases acetylcholine and is active anytime anything behaviorally relevant occurs in the environment (Richardson and Delong, 1991). Depleting cholinergic activity with antagonists prevents experience-dependent and injury-induced plasticity, while enhancing cholinergic activity with agonists facilitates cortical plasticity and learning (reviewed in Rasmusson, 2000). Traumatic brain injuries depress cholinergic activity (DeAngelis et al., 1994; Schmidt and Grady, 1995; Dixon et al., 1996, 1997a), perhaps limiting the effectiveness of traditional forms of therapy. Even though behavior may appear to have recovered (i.e., development of effective compensatory behaviors mediated by other neurotransmitters, adjacent tissue, etc.), the brain is extrasensitive to subsequent insults on the cholinergic system (Dixon et al. 1994).

Specifically, cholinergic activity is essential for cortical plasticity and experience-dependent recovery from brain damage (Conner et al., 2005). However, pairing electrical activation of nucleus basalis with sensory stimuli (i.e., making irrelevant stimuli seem really important) expands the corresponding area of the cortex in rats (Kilgard & Merzenich, 1998), and has the potential to facilitate recovery.

Accentuating Rehabilitation From a clinical standpoint, the effectiveness of therapy can be substantially increased with very specific activities that encourage reorganization of the affected neural pathways. For a comprehensive list of the clinical symptoms of auditory, visual, and vestibular processing disorders that may result from a traumatic brain injury, and some practical activities with which to effectively stimulate recovery, refer to the book Sensory Processing Disorders by Dr. Michelle MacAlpine (2006). The activities are fun for children and it is easy to increase task difficulty to capitalize on acetylcholine release and maximize the potential for beneficial plasticity.

Although behavioral activity alone can improve recovery of function, recovery may be accelerated if paired with manipulation of major excitatory neurotransmitter systems to create a permissive neural environment. Amphetamines, for example, increase several diffuse neuromodulators including noradrenaline, dopamine, serotonin, and acetylcholine, and have a positive influence even when administered only as a single dose at the beginning of therapy (Feeney et al., 1982).

Activating the cholinergic system with agonists after traumatic brain injury improves cognitive and motor performance and biochemical markers of brain activity (Dixon et al., 1997b; Verbois et al., 2003). However, targeted manipulation of the cholinergic system, and specifically of cholinergic neurons in nucleus basalis that project to the cortex, is likely to have a greater effect on plasticity (i.e., faster and more specific) than drugs. Research is currently underway to identify and develop cutting-edge treatments that aid recovery of function after central nervous system damage, including cell transplantation to enhance growth factor production and promote neuro- and synapto- genesis (Mahmood et al., 2005) and stimulation implants. Thalamic deep-brain stimulation decreases the severity of hand tremors in individuals with Parkinson’s disease (Pahwa et al., 2006), suggesting that stimulation may also be a safe and 28 BRAIN INJURY PROFESSIONAL

effective long-term treatment for other disorders of brain function. Combined with behavioral rehabilitation, nucleus basalis stimulation may be able to increase physiological plasticity and behavioral function in individuals with brain injuries.

Conclusions While the complex neurochemistry of learning remains poorly understood, the literature suggests that the act of learning, or rather relearning after brain injury, depends on the ability to attach meaning and significance to sensory experiences. Collectively, these results indicate that rehabilitative activities for people with brain injury should include meaningful sensory activities to stimulate the reorganization of the affected sensory or motor systems gradually over time.

About the Authors

Cherie Percaccio is a post-doctoral fellow in Theresa Jones’ lab at The University of Texas in Austin. She completed her bachelor’s degree in psychology from Texas A&M in 1999, a master’s degree in human development and early childhood disorders in 2001, and a master’s in cognition and neuroscience in 2002, both from UTD. In 2006, she earned her Ph.D. in cognition and neuroscience at UTD in Dr. Kilgard’s lab. Mike Kilgard is an Associate Professor in the Cognition and Neuroscience Program at The University of Texas at Dallas. In 1993, he completed his bachelor’s degree in molecular and cell biology from The University of California, Berkeley, and in 1998, earned his Ph.D. in Neuroscience from The University of California, San Francisco. Collectively, their research interests relate to the general principles that underlie the remarkable self-organizing capacity of the cerebral cortex, including the continual reorganization to optimize function in particular environments and more dramatic forms of reorganization that occur in response to injury. Dr. Percaccio’s research focuses on cholinergic modulation of plasticity in motor cortex and its application to stroke rehabilitation. The Kilgard lab uses targeted behavioral manipulations and stimulation of the cholinergic system to direct auditory cortex physiology. Regardless of which circumstance stimulates plasticity, understanding how brain networks can be driven to reorganize is critical for the development of rehabilitative therapies.

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Humm JL, Kozlowski DA, Bland ST et al., Use-dependent exaggeration of brain injury: is Recanzone GH, Schreiner CE, Merzenich MM, Plasticity in the frequency representation of glutamate involved? Exp Neurol. 157(2): 349-58, 1999. primary auditory cortex following discrimination training in adult owl monkeys. J Neurosci.

Humm JL, Kozlowski DA, James DC et al., Use-dependent exacerbation of brain damage occurs 13: 87-103, 1993. during an early post-lesion vulnerable period. Brain Res. 783(2): 286-92, 1998.

Recanzone GH, Jenkins WM, Hradek et al., Progressive improvement in discriminative abilities Itoh T, Satou R, Hashimoto S, et al., Isolation of neural stem cells from damaged rat cerebral in adult owl monkeys performing a tactile frequency discrimination task. J Neurophysiol. 67(5): cortex after traumatic brain injury. Neuroreport. 16(15): 1687-91, 2005.

•NeuroRehabilitation 1015-30, 1992a.

Jenkins WM, Merzenich MM, Ochs MT, et al., Functional reorganization of primary somato•NeuroBehavioral Rehabilitation Recanzone GH, Merzenich MM, Jenkins WM, et al., Topographic reorganization of the hand sensory cortex in adult owl monkeys after behaviorally controlled tactile stimulation. J Neurorepresentation in cortical area 3b owl monkeys trained in a frequency-discrimination task. J physiol. 63(1): 82-104, 1990.

•Adolescent Integration Neurophysiol. 67: 1031-56, 1992b.

Kernie SG, Erwin TM, Parada LF, Brain remodeling due to neuronal and astrocytic proliferation •Supported Richardson RT andLiving Delong Programs MR, Electrophysiological studies of the functions of the nucleus after controlled cortical injury in mice. J Neurosci Res. 66(3): 317-26, 2001. basalis in primates. Adv Exp Med Biol. 295: 233-52, 1991.

•Outpatient Services Kilgard MP, Merzenich MM, Cortical map reorganization enabled by nucleus basalis activity.

Schmidt RH and Grady MS, Loss of forebrain cholinergic neurons following fluid-percussion Science. 279: 1714-1718, 1998.

•Day Treatment / Outpatient injury: implications for cognitive impairment in closed head injury. J Neurosurg. 83(3): 496Kleim JA, Swain RA, Armstrong KA, et al., Selective synaptic plasticity within the cerebellar 502, 1995.

•Respite Services cortex following complex motor learning. Neurobiol Learn Mem. 69(3): 274-89, 1998.

Stein DG and Hoffman SW, Concepts of CNS plasticity in the context of brain damage and Kleim JA, Cooper NR, Vanderberg PM, Exercise induces angiogenesis but does not alter moveSupport repair.•Vocational J Head Trauma Rehabil. 18(4): 317-341, 2003. ment representation within rat motor cortex. Brain Res. 934(1): 1-6, 2002.

Steinmetz PN, Roy A, FitzgeraldResidential PJ, et al., Attention modulates synchronized neuronal firing in •Community-Based Services MacAlpine ML: Sensory Processing Disorders. Texas: Brain Training Associates, Inc., 2006. primate somatosensory cortex. Nature. 404(6774): 187-90, 2000.

Mahmood A, Lu D, Qu C, et al., Human marrow stromal cell treatment provides long-lasting Sur M, Garraghty PE, Roe AW, Experimentally induced visual projections into auditory thalabenefit after traumatic brain injury in rats. Neurosurgery. 57(5): 1026-30, 2005.

Partmusofand a National Network of Local cortex. Science.

242: 1437-1441, 1988.Providers Marklund N, Bakshi A, Castelbuono DJ, et al., Evaluation of pharmacological treatment strateTreue and Maunsell JH,Injury Effects ofServices attention on processing of motion in macaque middle MENTOR ABISoffers Brain inthethese locations gies in traumatic brain injury. Current Pharmaceutical Design. 12: 1645-1680, 2006. temporal and medial superior temporal visual cortical areas. J Neurosci. 19(17): 7591-602, 1999.

Nudo RJ, Adaptive plasticity in motor cortex: implications for rehabilitation after brain injury. IL CCS-Carbondale, REM-Minnesota Brain Injury Services J Rehabil Med. 41: 7-10, 2003.

Verbois SL, Scheff SW, Pauly JR, Chronic nicotine treatment attenuates alpha 7 nicotinic recepCCS-Florida REM-Iowa Brain Injury Services tor deficits following traumatic brain injury. Neuropharmacology. 44(2): 224-33, 2003.

Nudo RJ, Wise BM, SiFuentes F, et al., Neural substrates for the effects of rehabilitative training CCS-Kentucky REM-Health on motor recovery after ischemic infarct. Science. 272: 1791-4, 1996.

Whishaw IQ, Loss of the innate cortical engram for action patterns used in skilled reaching and CCS-New England REM-Colorado Brain Injury Services the development of behavioral compensation following motor cortex lesions in the rat. NeuroPahwa R. Lyons KE, Wilkinson SB, et al., Long-term evaluation of deep brain stimulation of the pharmacology.New 39(5):Jersey-MENTOR 788-805, 2000. thalamus. J Neurosurg. 104(4): 506-12, 2006.

CCS-Tennessee Xerri C, Merzenich MM, Peterson BE, et al., Plasticity of primary somatosensory cortex paralPercaccio CR, Engineer ND, Pruette AL, et al., Environmental enrichment increases pairedREM-Wisconsin CareMeridian leling sensorimotor skill recovery from stroke in adult monkeys. J Neurophysiol. 79(4): 2119-48, pulse depression in rat auditory cortex. J Neurophysiol. 94(5): 3590-6000, 2005.

Brain Injury Services 1998.

For more information contact Plautz EJ, Milliken GW, Nudo RJ, Effects of repetitive motor training on movement reprewww.mentorabi.com Zandt F, Prior M, Kyrios M, Repetitive children with high functioning autism and sentations in adult squirrel monkeys: role of use versus learning. Neurobiol Learn Mem. 74(1): Tollbehavior Free: in 800.203.5394 obsessive compulsive disorder. J Autism Dev Disord. [Epub ahead of print], 2006.

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29

Promising Practices for Youth with TBI Transitioning to Adulthood

by Bonnie Todis, Ph.D., James Malec, Ph.D. and Jane Gillett, MD-FRCP(C) Acknowledgements: This article is based on the discussion of members of the Transition to Adulthood and Community Discussion Group at the Galveston Brain Injury Conference, May, 2006. Other members of the discussion group are: Beatriz Abreu, Ph.D., Ramon Diaz-Arrastia, MD, Ph.D., Walter High, PhD., and Mark Sherer, PhD

al., 2003) found that in a sample of 90 adolescents with TBI in Oregon and Washington, two years after leaving high school only 61% were engaged in either work or post-secondary education, compared to 79% of national rates of engagement for youth with disabilities on the NLTS2 (Wagner et al., 2005).

Other PSO findings include:

Despite the high incidence of TBI in children and adolescents (CDC, 2005), only recently have researchers examined the post-school outcomes of young adults who sustain TBI during childhood. Outcomes for students with TBI were not reported in the first National Longitudinal Transition Study (NLTS) (Blackorby and Wagner, 1996). In the second such study (NLTS2) (Wagner et al., 2005) outcomes for youth with TBI were significantly worse than those for other disability groups. Approximately 50% of the students with TBI were employed, and only 22% were enrolled in post-secondary education or training programs. In contrast, across all disability groups, NTLS2 found that 62% were employed and 55% participated in post-secondary education.

The first longitudinal transition outcomes study for youth with TBI (Post-Secondary Outcomes of Students with Traumatic Brain Injury [Project PSO] (Glang et al., 1998; Glang et

• Only 40% were employed two years after graduation • Of those who were employed, 64% were working in menial or unskilled jobs • Less than half the sample received transition services and only 36% had a written transition plan • After controlling for severity of injury, participants who received special education services while in high school had no better outcomes than those who did not.

30 BRAIN INJURY PROFESSIONAL

Thus, regional and national research findings indicate that there is a pressing national need for services to improve transition outcomes for adolescents with TBI. Current transition services.

The federal Office of Special Education’s Transition Initiative was implemented in the mid 1980s with the goal of improving

the post-school community adjustment of students with disabilities (Savage, 2005; Will, 1984). The Individuals with Disabilities Act (IDEA, 1997; 2004) mandates transition services for students with disabilities starting at age 16. IDEA specifies that these services are to take the form of a “coordinated set of activities” designed to promote “movement from school to post-school activities, including postsecondary education, vocational training, integrated employment (including supported employment), continuing and adult education, adult services and independent living or community participation.”

In the last 20 years, researchers have identified promising components of transition interventions that improve adult outcomes for many students with disabilities (Bullis and Fredericks, 2002; Hasazi et al., 1999). However, many in the field of special education would assert that transition services have not lived up to their promise. Students in each of the 11 disability categories and as an overall group have transition outcomes that are significantly worse than those of young adults who do not have disabilities (Wagner et al., 2005). These outcomes reflect the fact that transition has always been an “under-funded mandate.” That is, funds were not allocated when special education law was amended to cover the full cost of transition services. Thus, IEP teams have struggled to develop low cost programs that would prepare students for adulthood.

IEP teams of students with TBI faced the additional difficulties of lack of educator training and the fact that many students experience TBI at age 16 and up, in motor vehicle crashes that occur soon after they receive drivers’ licenses. Parents and students in this situation are often reluctant to give up on the students’ preinjury plans and dreams, and may therefore continue with preparation for college, rather than explore other transition options.

Although students with disabilities are entitled to receive special education services until age 22 (IDEA, 2004), many students with disabilities, including many students with TBI injured near the end of high school, choose to graduate with their classmates, thereby terminating their special education eligibility. Such students are often surprised to find that their disabilities are not just school-related but also prevent them from maintaining employment and being successful in postsecondary education. In the National Transition Longitudinal Study, one to two years after their children left high school, over 70% of parents of students with TBI indicated that their children needed additional services in order to live independently, a higher rate than parents in any other disability category. Over 60% of parents indicated that young adults with TBI needed vocation services, specifically.

Clearly, current school-based transition services are not adequately preparing students with TBI for life after high school and are not linking them with community based services that can provide them with on-going assistance. A promising approach for improving transition services is currently in use with adults with TBI in the US and with children with TBI in Canada.

Case Management Model (CMM) Case management (CM) has proven to be an effective vocational rehabilitation model for adults with TBI, one assures

that all life domains—health, social, family, school, work— are addressed and that support systems and environments are considered in planning vocational and community reintegration.

The case manager assists the client and family in developing a self-directed, client-focused plan for medical care, rehabilitation and social reintegration and in establishing a network of medical center- and community-based services and supports.

Initial contact with both medical and vocational case management providers occurs soon after injury. Even if vocational and community integration goals are months or years away, early intervention helps keep a return to routine life “on the radar” for people with TBI and their families. Throughout a process that may extend for several years, planning remains fluid to accommodate changes in those served and their interactions with the social and physical environment. Multiple work trials to help clients identify and adapt to work situations where they can succeed as well as opportunities for short- or long-term supported-employment and employer-peer education are other critical features of a CMM. Compared to the costs of medical care and treatment and medical rehabilitation, the additional cost of case management and supported employment services is relatively small.

With these specialized TBI vocational services, employment rates increase dramatically. One year after initial placement, Malec et al. (2000) reported an employment rate of 81% for 114 of people with TBI served by a medical/vocational CM system. These findings were replicated in a study by Malec and Moessner (2005). In contrast, other studies of long-term employment for adults with TBI consistently report rates below 30% (Wehman et al., 1993; Ysuda et al., 2001) Pediatric Case Management Model In Ontario, Canada, a pediatric case management approach has been developed to meet the needs of children with TBI and their families who live in rural areas. This approach, called the Pediatric Acquired Brain Injury Community Outreach Program (PABICOP) is designed to be comprehensive, holistic, and family centered and to involve the community in the ongoing care of the child or youth with TBI (Gillette, 2004).

A team consisting of a pediatric neurologist, community outreach worker, school liaison, and appropriate rehabilitation specialists conducts in depth assessments, including a home visit and interviews with the child’s parents and teachers. Based on the family’s need, the Outreach Coordinator may provide access to counseling services, behavior management training, and other social services. The school liaison provides training and consultation to school personnel, and medical and rehabilitation services are provided by other PASICOP team members. Children with severe TBI are seen by the team every three to four months for the first year, then every six months for the next couple of years. Children and youth are then followed on a yearly basis.

Although demonstration of the success of programs using a CMM for vocational rehabilitation after TBI has been generally confined to adults, and the PABICOP is designed for school-aged children and youth, both models seem viable for application during secondary education and compatible with existing school administrative structures.

BRAIN INJURY PROFESSIONAL

31

Adapting the Case Management Model to improve transition outcomes The current transition mandate under IDEA provides the critical framework for an effective approach to transition for students with TBI. By incorporating a case management component and extending the case manager’s role into the post-secondary years, CMM would ensure continuous support for young adults with TBI and their families across vocational, educational, social and independent living domains. Working with the student, family, educators, and service agency personnel, beginning at age 16 or earlier, the case manager would assist with development of a transition plan and identify steps to achieving this plan. The provision of on-going CM throughout the first years of transition also offers an opportunity for case managers to work with personnel from public service agencies to improve their skills and services to better meet the needs of individuals with TBI across the age span.

Fortunately, it is not necessary to “start from scratch” to develop and test the CM model for use with youth with TBI. A similar model has been in place for over ten years in Oregon and in several other states including Arizona and Alabama and has undergone rigorous testing by special education researchers.

Youth Transition Program The Youth Transition Program (YTP) is a cross-agency intervention based on many years of research in effective transition supports (Blackorby and Wagner, 1996; Bullis and Fredericks, 2002; Halpern et al., 1995; Heal and Rusch, 1995; McGrew et al., 1992; Wehmeyer and Schwartz, 1997). The model features a collaboration among the state Department of Education, Vocational Rehabilitation Services, and local school districts.

Through YTP, students receive: (a) transition planning focused on post school goals, self-determination, and linkages with relevant adult agencies; (b) instruction in academic, vocational, and independent living areas, (c) help to stay in school and obtain a completion document; (d) paid job training while in the program, and help to secure employment or enter postsecondary training upon leaving the program; and (d) follow-up support services for a year or more after leaving the program. A school district transition specialist and a counselor from the local VR field office work as a team with the student through all stages of the program.

Evaluation studies have found that 90% of YTP participants obtained a high school completion document; 82% were placed successfully in a competitive job, postsecondary training, or a combination of both at the point of program exit; and rates of engagement in employment or education remained consistently above 80% for program completers during the follow-up period (Horne and Hubbard, 1995; Rogers et al., 1995). YTP youth had better employment outcomes than transition-age youth who received vocational rehabilitation services but did not participate in YTP (Benz et al., 1999).

Conclusion Opportunities are available through the US Department of Education to develop and validate practices that lead to improved transition outcomes for students with disabilities. A 32 BRAIN INJURY PROFESSIONAL

case management model for providing transition services for students with TBI appears to be a promising approach worth investigating.

About The Author

Dr. Todis is an Associate Research Professor at TRI and director of a longitudinal study of transition outcomes in young adults with TBI. She has conducted several studies of the school experiences of students with TBI and of effective instructional practices for use with these students.

Dr. Malec is the Principle Investigator of the Mayo Clinic TBI Model System project. The project focuses on: (a) Decision-making and outcomes of inpatient and outpatient rehabilitation pathways; (b) Very long term (5-15+ years post-injury) process and outcome for people with TBI identified through the Rochester Epidemiology Project; and (c) Telehealth-based (internet) cognitive rehabilitation.

Dr. Gillett is a pediatric neurologist and medical director of the Acquired Brain Injury Program in Hamilton, Ontario. She created and developed the Paediatric Acquired Brain Injury Community Outreach Program (PABICOP) at the Children’s Hospital of Western Ontario.

References

Benz MR. Lindstrom L. Latta T, Improving collaboration between schools and vocational rehabilitation: The Youth Transition Program. Journal of Vocational Rehabilitation. 13(1):55-63, 1999.

Blackorby J. Wagner M, Longitudinal postschool outcomes of youth with disabilities: findings from the National Longitudinal Transition Study. Exceptional Children. 62:399-414, 1996.

Bullis M. Fredericks HD, Providing Consultation and Technical Assistance. In: Vocational and Transition Services for Adolescents With Emotional and Behavioral Disorders. Champaign, IL: Research Press, pp. 173-184, 2002.

Centers for Disease Control, Interactive Data Tables. Available at: http://www.cdc.gov/nchs/ health_data_for_all_ages.htm. 2005.

Gillett J, The Pediatric Acquired Brain Injury Community Outreach Program (PABICOP) – An innovative comprehensive model of care for children and youth with an acquired brain injury.

NeuroRehabilitation. 19(3):207-18, 2004.

Glang A. Todis B. Bullis M, Resilience in Students with Traumatic Brain Injury: A Longitudinal Investigation. U.S. Department of Education National Institute on Disability and Rehabilitation Research, Field Initiated Research Projects, Grant # H133G030179, 2003.

Glang A. Todis B. Bullis M, Resilience in Students with Traumatic Brain Injury: A Longitudinal Investigation. Post-Secondary Outcomes for Students with Traumatic Brain Injury. U.S. Department of Education, Office of Special Education Programs, Field Initiated Research Studies, Grant # H324C980115, 1998.

Halpern AS. Yovanoff P. Doren B, et al., Predicting participation of school-leavers with disabilities in post-secondary education. Exceptional Children. 62:151-164, 1995.

Hasazi SB. Furney KS. DeStefano L, Implementing the IDEA transition mandates. Exceptional Children. 65(4):555-566, 1999.

Heal L. Rusch F, Predicting employment for students who leave special education high school programs. Exceptional Children. 61(5):472-487, 1995.

Horne RL. Hubbard S, The Youth Transition Program: Case study report. Washington, DC: National Institute for Work and Learning, Academy for Educational Development, 1995.

Individuals with Disabilities Education Act Amendments of 1997. (P.L. 105-17). 20 U.S.C. 1400 et seq. 1997.

Individuals with Disabilities Education Act Amendments of 2004. (PL 108-446), 20 USC 1400 et seq. 2004.

Malec J. Moessner A, Replicated positive result for the VCC model of vocational rehabilitation after ABI within the social model of disability. Brain Injury. 20(3):227-236, 2006.

Malec J. Moessner A. Kragness M, et al., Refining a measure of brain injury sequelae to predict postacute rehabilitation outcome: rating scale analysis of the Mayo-Portland Adaptibility Inventory (MPAI). Journal of Head Trauma Rehabilitation. 15(1):670-682, 2000.

Rogers A. Hubbard S. Charner I, et al., Learning from experience: A cross-case comparison of school-to-work transition reform initiatives. Washington, DC: National Institute for Work and Learning, Academy for Educational Development, 1995.

Savage RC, The great leap forward: Transitioning into the adult world. Preventing School Failure.

49(4):43-52, 2005.

Wagner M. Newman L. Cameto R, et al., After high school: A first look at the postschool experiences of youth with disabilities. A report from the National Longitudinal Transition Study-2 (NLTS2). Menlo Park, CA: SRI International, 2005. Available at: http://www.nlts2.org/nlts2_textonly/reports/reports_collapsed.html.

Wehman P. West M. Sherron P, et al., Return to work: supported employment strategies, costs, and outcome data. In: Community-Based Employment Following Traumatic Brain Injury. DF Thomas, FE Menz & DC McAlees (Eds.) Menomonie, WI: University of Wisconsin-Stout, 1993.

Wehmeyer M. Schwartz M, Self-determination and positive adult outcomes: A follow-up study of youth with mental retardation or learning disabilities. Exceptional Children, 63(2):245-255, 1997.

Will M: OSERS program for the transition of youth with disabilities: Bridges from school to working life. Washington, DC: Office of Special Education and Rehabilitation, 1984.

Yasuda S. Wehman P. Targett P, et al., Return to work for persons with traumatic brain injury.

American Journal of Physical Medicine & Rehabilitation. 80(11):852-64, 2001.

Student Under-Identification after TBI

The Back to School project, funded by the Office of Special Education Projects and conducted at the Teaching Research Institute, is the first empirical study of factors that contribute to the under-identification of students with TBI. In this project, researchers Ann Glang and Bonnie Todis at the Teaching Research Institute are tracking a sample of 136 students with TBI as they leave hospitals and rehabilitation setting to return to school. The study is exploring factors that influence identification and service practices for these students. Parallel to the national figures, findings suggest that children in the sample are under-identified for special education. Fifty-nine percent of children who were hospitalized for TBI and experienced challenges in academic and/or social-behavioral skills were not referred for special education services when they returned to school. Preliminary analyses indicate that there are several key factors contributing to under-identification.

One factor is the lack of coordination between the hospital and school during the transition back to school. In the Back to School sample, only 45% of parents reported that there was communication between the hospital and school about their childrenâ&#x20AC;&#x2122;s injury. Another factor in under-identification appears to be the lack of awareness and training on the part of educators regarding TBI and its educationallyrelevant consequences. In the Back to School study, an overwhelming 92% of educators reported having no training in TBI. Finally, parents in the study indicated that they did not receive any information about childhood brain injury before their children returned to school, which impedes their ability to advocate for the school services and supports that would most benefit these students.

Conference AD

For students who have sustained a brain injury, proper identification is an essential first step to insuring appropriate educational services. Findings from the Back to School project suggest that many students with TBI are currently experiencing difficulty in one or more school domains, yet are not identified for special education and in fact are not receiving school services to address their problems.

Bonnie Todis, PhD information:todisb@wou.edu BRAIN INJURY PROFESSIONAL

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tbi technical assistance center

The Federal Traumatic Brain Injury (TBI) Program is administered by the Health Resources and Services Administration’s Maternal and Child Health Bureau (MCHB). The Program’s vision is that all individuals with TBI and their families will have accessible, available, acceptable, and appropriate services and supports. The Federal TBI Program awards grants to States to conduct activities determined by what needs to be done to expand or improve their systems of services and supports, and what is best suited to the development of the State. Between 1997 and 2006, 48 States, two Territories, and the District of Columbia have received at least one State Agency grant. To assist States, the Federal TBI Program supports the TBI Technical Assistance Center (TBI TAC) at the National Association of State Head Injury Administrators (NASHIA). (For more information on the Federal TBI Program, visit http://www.mchb.hrsa.gov/programs/tbi.htm.)

Behavior Assessment and Problem Solving, Using Positive Behavior Supports for Students with Traumatic Brain Injury This two-hour Webcast developed by the TBI TAC, focuses on why it is important to correctly identify students with TBI and provide them with appropriate supports and services. This Webcast is a valuable training resource for teachers, special educators, school nurses, and other school personnel working with students with TBI. This Webcast is available from MCHB for download at www.mchcom.com/archivedWebcastDetailNewInterface.asp?aeid=373.

Recognizing children and youth as an important issue, the Federal TBI Program designated the identification and appropriate service delivery of students with TBI as one of the Program’s two priority areas. An expert panel has been guiding the TBI TAC’s staff in examining promising practices in screening and resource linkage for children and youth. Selected children and youth resources recommended by the work group are listed below.

Traumatic Brain Injury Facts: Children and Youth (Fact Sheet) This fact sheet provides the medical and Individuals with Disabilities Education Act definitions for TBI; describes the various causes and consequences of TBI for children and youth; and describes the educational supports available for students with TBI and their families. This fact sheet is available from the TBI TAC’s TBI Collaboration Space (TBICS) for download at www. tbitac.nashia.org/tbics/download/children.pdf.

Selected Resources for School Personnel and Families of Students with Traumatic Brain Injury This list of selected resources was created by a work group of the TBI TAC’s Children and Youth committee. The selected resources are categorized by media with each category listed alphabetically. This list is available for download at www. tbitac.nashia.org/tbics/download/selectedresources.pdf.

When Your Child’s Head Has Been Hurt (Fact Sheet) This publication helps families, school nurses, pediatricians, and other children’s health specialists identify post concussive disorders after discharge from the emergency department or hospital. Created by the Arizona State Agency TBI Grant, this fact sheet is available from the TBI TAC’s TBICS for download at www.tbitac.nashia.org/tbics/download/azheadfs.pdf.

BRAIN INJURY PROFESSIONAL

35

non-profit news Brain Injury Association of America

International Brain Injury Association

The midterm election gave Democrats a clear majority in Congress and established “oversight” as the most frequently used buzz word among Washington’s talking heads. BIAA is poised to take advantage of the new lawmakers’ inclination to hold Federal agencies and corporate America responsible for their action.

In November, the Board of Directors ratified BIAA’s position statement, Cognitive Rehabilitation: The Evidence, Funding and Case for Advocacy, calling on policymakers and private sector payers to eliminate the barriers in accessing and delivering cognitive rehabilitation. In addition to increased emphasis on research, clinical education, and expanded scope, duration and intensity of service coverage, BIAA’s 15-page white paper recommends improved integration of cognitive treatment in public vocational and social services as well as greater attention to the needs of children. The position statement is available from BIAA’s website at www.biasua.org.

BIAA partnered with American Congress of Rehabilitation Medicine colleagues to lobby National Institute on Disability and Rehabilitation Research officials and Congressional appropriators for increased TBI Model Systems funding. BIAA also collaborated with national stakeholder organizations on TBI Act reauthorization and appropriations as well as Defense and Veterans Brain Injury Center (DVBIC) funding.

Blast brain injury was featured as part of the David Strauss Memorial Lecture Series offered by BIAA’s American Academy for the Certification of Brain Injury Specialists. There are now more than 2000 AACBIS certificants nationwide and efforts are underway to make it easier for larger rehabilitation facilities to train and certify more staff simultaneously.

In November, BIAA hosted the Brain Injury Business Practice College, which focused on the theme of Co-Opetition and included sessions on succession and emergency planning, business development, public relations, ethics and more. The pre-conference workshop, which employed the Harvard Business School method of case study, tackled personnel issues.

BIAA completed a 3-year cooperative agreement with the CDC to test telephone technology that can automatically route Helpline callers to state affiliates. The project included development of training manuals and resource/information materials. Right now, staff and volunteers are hard at work on the Brain Injury Awareness Month Campaign. March 2007 marks the fourth and final year of CDC grant support for development, design and distribution of the awareness tool kits.

Now more than ever, BIAA needs tax-deductible contributions from brain injury professionals. Please visit our website at www.biausa.org and make a generous donation.

IBIA continues to plan for its next International Congress in 2008. A scientific planning committee with international representation will be assembled to assist with the program planning for the meeting which will be held in April 2008. Please check in periodically for updates to the IBIA website at www. internationalbrain.org. IBIA is also currently planning to work with WFNR to plan a conjoint meeting on MTBI associated with the 2008 international congress. We encourage IBIA members to begin to think about papers and talks for submission to the meeting.

IBIA membership benefits abound including a subscription to the peer-reviewed international scientific journal, Brain Injury, the official endorsed journal of IBIA. Regular issues of the NeuroTrauma Letter, the web-based publication of IBIA, continue to provide up to date information regarding current topics and controversies in the field of brain injury medicine and rehabilitation, new book announcements, product reviews, current literature and book reviews. The use of our list serve is an additional member benefit as are discounts on key publications such as Dr. Zasler’s latest multi-author edited text: “Brain Injury Medicine: Principles and Practice”. Members also receive significant discounts on IBIA sponsored meetings including the biennial international congress.

IBIAs Chairperson, Nathan Zasler, MD and Treasurer, Jose Leon Carrion, PhD recently were invited speakers at the 6 th Mediterranean Congress of PRM in Villamoura, Portugal in October 2006. There talks were extremely well received. Dr. Zasler also had the opportunity to assist Dr. Jorge Lains, the conference chairperson, with the assessment and treatment planning of one of his more challenging patients with TBI related neurobehavioral problems.

IBIA is also very pleased to note that two of its members have recently published major textbooks in the field of brain injury: Brain Injury Treatment Theories and Practices by Jose Leon-Carrion, Klaus R. H. von Wild, George A. Zitnay; and Brain Injury Medicine Principles and Practice by Nathan D. Zasler, MD, Douglas I Katz, MD and Ross D. Zafonte, DO (Editors).

36 BRAIN INJURY PROFESSIONAL

North American Brain Injury Society The North American Brain Injury Society is pleased to announce that the NABIS Fifth Annual Brain Injury Conference will be held September 27 through 29, 2007, at the Westin Riverwalk Hotel in San Antonio, Texas. The Westin Riverwalk is located on the famous Paseo del Rio waterway, only steps away from San Antonio’s historic Alamo.

The 2007 conference will be co-Chaired by NABIS Executive Vice President Ron Savage, EdD, and Texas Brain Injury

Society Chairman, David Seaton. The Conference will feature four concurrent education tracks covering the following topic areas: Medical/Clinical, Research, LifeLong Living, and Legal Issues. Building on the success of our 2006 pre and post conference workshops, the program chairs will be adding several “hands on” format panel discussions that will address the practical issues facing brain injury professionals.

The poster program will be under the direction of Mariusz Ziejewski, PhD. Look for the Call for Abstracts on www.nabis. org during the first quarter of 2007. New this year, the poster sessions will be expanded and awards will be given to the top three scoring presentations.

As in years past, this conference will be held in conjunction with the Legal Issues in Brain Injury Conference. Now in its 19th year, the Legal Conference will be Co-Chaired by Bruce Stern, Esq., Simon Forgette, Esq., Kenneth Kolpan, Esq., and Robert Voogt, PhD. The Exhibitor/Sponsor prospectus for the combined event will be available in January 2007. For more information, contact Joyce Parker at (713) 526 6900 or via email, jparker@ nabis.org.

NABIS Chairman of the Board Robert Voogt, PhD, is pleased to announce the following new members to its Board of Directors: Brent Masel, MD, Tina Trudel, PhD, and Barry Willer, PhD. Finally, NABIS welcomes your comments and suggestions for ways that we can improve our services to the professional community. We encourage you to stay abreast of our activities by visiting our website, www.nabis.org.

National Association of State Head Injury Administrators The National Association of State Head Injury Administrators (NASHIA) remains focused on advocating for the reauthorization of and funding for the Traumatic Brain Injury (TBI) Act. With the changes in Congressional leadership for the next session of Congress, it is anticipated that the reauthorization of the TBI Act and FY 07 (and 08) appropriations will be left to the new Congress that will begin its work in January 2007. We need to ensure that funding of the TBI Act equates to $21 million for the HRSA Federal TBI Program to provide funding for States ($15 million) and Protection & Advocacy Systems ($6 million); and $9 million for the Centers for Disease Control and Prevention TBI Program. Your assistance is needed as the budget environment will be challenging. It will be difficult to hold onto the current amount of $8.91 million earmarked for the HRSA Federal TBI Program in FY 07 without your strong support.

At the State of the States in Head Injury meeting in September, many members were engaged by the discussion around homelessness and traumatic brain injury. To look at the is-

sue in more depth and to identify and address some of the challenges, the NASHIA Board has established a Homelessness Task Force.

The Deficit Reduction Act presents new provisions for increased State flexibility in providing Medicaid benefits. The NASHIA Policy Committee is reviewing the information to identify some of the possible effects for individuals with TBI. Be sure to check out the NASHIA website (www.nashia. org) to see the latest on state systems development to meet the needs of individuals with brain injury and their families.

National Brain Injury Research, Treatment & Training Foundation A nationally renowned panel of Neuroscientists met on Capitol Hill in November 2006, to urge more funding for the research, treatment and rehabilitation needs of individuals who sustain a Traumatic Brain Injury (TBI). The group presented to Congress two comprehensive reports on TBI. The Conemaugh and Mohonk Reports presented extensive research, recommendations and guidelines for the treatment and care of those sustaining a TBI. The Reports conclude with ‘A Call for Action’ for Congress to urgently increase annual TBI funding levels by $100 million for programs to address an alarming rise in Brain Injuries both at home and among our brave service personnel in Iraq and Afghanistan.

Dr. George A. Zitnay, founder of the National Brain Injury Research, Treatment & Training Foundation (NBIRTT) which sponsored the Roundtable led the charge bringing together advocates and experts to discuss ‘the way forward.’

“These groundbreaking studies lay out for our policymakers a pathway towards a successful recovery from TBI but we must act now,” stated Zitnay in summarizing the goals for the guests, members of Congress, Hill staff and the media. TBI is the signature injury of the war in Iraq and on terrorism. At home, 1.6 million Americans suffer a TBI each year, with an annual cost of $60 billion.

Along with Zitnay, Dr. Joseph Fins, Dr. Joseph Giacino, Dr. Jean Langlois, Dr. Donald Marion, Dr. John Povlishock, Dr. Beverly Walters, Dr. John Whyte, and Dr. Ross Zafonte participated in the forum. They discussed what the future holds for TBI patients and their family members.

Rep. Patrick Kennedy (D-RI) called for “parity” in federal funding levels for TBI as a critical link in our nation’s health care needs. In addition to Kennedy, Rep. Bill Pascrell, Jr. (D-NJ), Co-Chair of the Congressional Brain Injury Task Force and his colleagues, Rep. Brian Baird (D-WA), Rep. Virgil Goode (R-VA), Rep. Bill Jenkins (R-TN), and Rep. Robin Hayes (RNC), participated along with key staff from the House and Senate. For more information, visit www.nbirtt.org.

BRAIN INJURY PROFESSIONAL

37

More than

Traumatic Brain Injury Serving the community for two decades, Beechwood has expanded its TBI offering to encompass broad neurological services as well as new Behavioral Remediation and Late Adolescent programs.

In addition to TBI, we serve individuals with brain damage due to: • Anoxia/Hypoxia due to drowning, heart attack, drug overdose, alcohol poisoning, anesthesia errors, etc.

• Electric shock/lightning strike • Degenerative diseases • Infectious diseases • Early stage moderate dementias • Tumors • Brain surgeries • Many neurological disorders

conferences 2007 FEBRUARY 15-17 – Pacific Coast Brain Injury Conference in partnership with the Brain Injury Association of Canada presents Canada’s National Brain Injury Conference.

Hyatt Regency, Vancouver, BC, Canada. Contact: (604) 949-0716, www.pcbic.org.

MARCH 9-11 – International Congress on Neurology and Rehabilitation (ICNR), New Delhi, India. Contact: icnr2007@gmail.com, web: www.iamst.com.

• Stroke For information and admissions, call 1-800-782-3299.

Our facilities are adapted to accommodate all levels of accessibility.

REHABILITATION

SERVICES

A Community-Integrated Brain Injury Program An affiliated service of Woods Services, Inc. www.beechwoodrehab.org

Langhorne, PA • Bensalem, PA

APRIL 9-27 – Certificate Course in Neurological Rehabilitation, Newcastle upon Tyne, UK. Contact: traceymole@wfnr.co.uk.

MAY 24-26 – 2nd Biennial International Conference on Vocational Outcomes in Traumatic Brain Injury. Vancouver, BC Canada. Contact: (604) 875.1775, www. tbicvancouver.com, sljproductions@telus.net JUNE 10-14 – 4th World Congress of the International Society of Physical Medicine and Rehabilitation, Seoul, Korea. Contact: isprm2007@intercom.co.kr, www. isprm2007.org.

16-19 – Advances in Neurorehabilitation: Part of The Festival of International Conferences on Caregiving, Disability, Aging and Technology (FICCDAT), Toronto, Canada. Contact: catherine@smartmove.ca, www. ficdat.ca.

16-20 – 17th Meeting of the European Neurological Society, Rhodes, Greece. Contact: www.ensinfo.com.

18-20 – 2nd Neurorehabilitation Panamerican Congress. Buenos Aires, Argentina. Contact: dfelder@ ineba.net, web: www.ineba.net.

22-24 – Joint Meeting of WFNR and EMN, Fiuggi, Italy.

Contact: fservade@ausl-cesena.emr.it, www.emn.cc AUGUST 25-28 – 11th Congress of the European Federation of Neurological Societies, Brussels, Belgium. Contact: headoffice@efns.org, web:: www.efns.org/efns2007.

SEPTEMBER 24-27 – 5th World Congress for NeuroRehabilitation, Rio de Janeiro, Brazil. Contact: traceymole@wfnr. co.uk.

27-29 – North American Brain Injury Society’s Fifth Annual Conference on Brain Injury, Westin Riverwalk, San Antonio, Texas. Contact: conference@nabis.org, www.nabis.org.

27-29 – 19th Annual Conference on Legal Issues in Brain Injury, Westin Riverwalk, San Antonio, Texas.

Contact: conference@nabis.org, www.nabis.org.

38 BRAIN INJURY PROFESSIONAL

A Continuum of Care for Adults & Children with Brain Injuries.

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