Final copy

Chapter One

Introduction

What is TBI? TBI stands for Traumatic Brain Injury “From 2001 to 2009, the

estimated number of sports and recreation related TBI visits to emergency departments

(EDs) increased from 153,375 to 248,418, and the estimated rate of TBI visits increased

from 190 per 100,000 population to 298.” (MMWR, 2011, p2). Courville and others

states:

Traumatic brain injuries (TBI) are the most common cause of brain damage in the

western world. Direct impact to the skull along with rapid acceleration–

deceleration of the brain within the skull cavity leads to multifocal and diffuse

injuries, with pathology typically concentrated in the ventrolateral and orbital

frontal lobes and the temporal lobes (Courville, 1945; Gentry, Godersky, &

Thompson, 1988; Hadley et al.,1988)

For educators, parents, and students with TBI, TBI can be translated into just one word—

Devastating. Pieper in 2001 best described it by stating, “those experiencing traumatic

brain injury (TBI) is that they often express frustration and pain at ‘“losing”” the child

they knew.” (p 5). The purpose of this project is to try to alleviate this frustration. Some

of the ways to alleviate frustration are to acquire information, knowledge, and strategies,

to deal with issues. This project does just that, with the design of an interactive website,

with practical research-based learning strategies, that demonstrate and model effective

tools for working with students with TBI.

Masters Project TBI 2

Educators are constantly looking for new ways to teach in order to deliver our

most effective lessons to all children. “Thus, it is not surprising that educators have

sought to incorporate neuroscience research findings into the special education

classroom.” (Alferink & Dugan, 2010, p 42). “Special educators strive to arrange their

classrooms to elicit the best learning outcomes.” (p 42) In the same article, According to

quoted authors such as Sprenger (1999), arrangements that are brain compatible should

elicit the best learning. More speciﬁcally, Sprenger and others suggested that this can be

accomplished by teaching to different learning styles or a child’s multiple intelligences.

(p43)

Statement of the Problem

There is plenty of research on how TBI occurs and how it debilitates the brain, but

there are few strategies available to parents and educators, to help a child with TBI re-

learn to function. During the past several months, this Educator, was providing

instruction with a child who has suffered a TBI. This required spent many hours

researching TBI to determine what strategies are practical and effective for a student with

TBI. (See Appendix).

There are several websites providing information about TBI. The availability of

comprehensive and practical strategies for working with children with TBI is woefully

absent. This web site was developed to provide a comprehensive website that provides

information on TBI and strategies for parents, educators, and students. This website

provides effective and practical methods for addressing the education needs and will tools

to re-assimilate children with TBI with life skills.

Background and Need


“Students with brain injuries tend to have cognitive problems in four areas:

attention and concentration, information processing, memory, and executive functions.”

(Disability Rights Network, 2008 p12). Working with someone who suffered Hypoxic-

Anoxic Bran Injury, caused by strangulation started this quest. Hypoxic-Anoxic Brain

Injury is one of the many types of TBI. According to the Brain Injury Association of

America, Hypoxic refers to a partial lack of oxygen and Anoxic means a total lack of

oxygen. Therefore, the more complete the deprivation of oxygen to the brain the more

severe the damage to brain. This will then result in the greater the consequences (p. 1)

After testing the student, the student results were two-standard deviation drops in

all areas of academia from previous testing. The school psychology report also showed a

two standard deviation drop as well. The biggest loss for this student is memory,

especially short-term memory. Intervention for this student included support in math,

reading, and writing. Each of these areas, the memory processing is largely affected.

Research showed several methods to help a student with TBI but no modeling or

physical visual representation. The majority of the websites researched for methods and

strategies stated something like this:

• Use a multi-modal approach (overheads, videos, hands-on activities) when

presenting material and instructions for assignments.

• Teach compensatory strategies to students and structure choices.

• Begin class with review and overview of topics to be covered.

• Provide the student with an outline of the material to be presented, to assist in

comprehension.

• Emphasize main points and key ideas frequently.


• Incorporate repetition into instruction.

• Provide specific, frequent feedback on student performance and behavior.

• Encourage questions.

• Break down large assignments into smaller components.

• Use task analyses to determine skill acquisition and maintenance.

• Ask the student how he or she could improve learning.

• Use a variety of open-ended and multiple-choice questions to encourage

independent thinking.

• Present difficult material in a simplified fashion, using illustrations or diagrams

if possible.

• Provide the student with cues when appropriate.

(Louie, Brett, et al. , 2002, p 65)

The main question is what does this really look like to a teacher or parent? How do you

apply these strategies? How do these strategies differ than other strategies? How will this

part access that needed rouge memory.

Rationale

A report to Congress, December 1999 (http://www.cdc.gov/ncipc/pub-

res/mtbi/mtbireport.pdf), “TBI is the leading cause of death and disability among children

and young adults in the United States.” (p. 1). Teachers many times do not even know a

student has TBI because there are no visible damages. Unless the parent has reported to

the school that the child has suffered a TBI, there is no way to know. In the same report

the disabilities and impairments are described, “TBI is referred to as the invisible

epidemic these disabilities arising from cognitive, emotional, sensory, and motor


impairments often permanently alter a person’s vocational aspirations and have profound

effects on social and family relationships.” (p. 1-2). Educators, are required to instruct

and educate all children. According to the Free Appropriate Public Education for

Students With Disabilities: Requirements Under Section 504 of The Rehabilitation Act of

1973 states “education services designed to meet the individual education needs of

students with disabilities as adequately as the needs of nondisabled students are met.” As

educators we need to have strategies that are proven effective, and research-based. So

which strategies do we use? Where can we find the most information possible to

complete this directive? That is what this project is going to provide creating one source

of effective, research-based strategies that are modeled and available, for educators and

parents.

Purpose of the Project

The purpose of this project is to provide an interactive website for educators and

parents with information about TBI other websites and to provide tools and strategies to

help students with Traumatic Brain Injury (TBI).


The website includes a Home page with information about the website

An Information page provides medical information, services available, and other

important information.


There also is a survey link on the first page to allow for the informal evaluation of the

website. This includes

• Evaluation of research based strategies

• Recommendations

• Overall effectiveness of the website

Math Strategies page provides teaching strategies for Mathematics. This includes video

links to teacher’s modeling the strategy and information as to why it might be effective.


Language Strategies page provides teaching strategies for English Language Arts (ELA).

This page also provides links to videos that have educators modeling the strategies, and

why they might be effective.

Memory Tools: This includes links to memory games, practices, and strategies that

might be effective for improving memory. (see ELA-same format)


The last page is a list of all Links that this author has found, on TBI, and strategies for

teaching students with TBI.

This website may be helpful to all educators, however; this website was geared to the

demographics of educators and parents of children who have TBI

Project Objectives

• To research best practices strategies to use with individuals with TBI.

• To create a website where information is available for students with TBI

• To create a website for teachers and parents to find and practice reached based

strategies for Mathematics, English language Arts and Memory

o Effectiveness of the students with TBI determined which strategy used

o Videotaped and uploaded to the website,

o The strategy used is not a recommendation of one strategy over another

strategy.

Definition of Terms all terms have been defined in the chapter.


CHAPTER 2

What is TBI? TBI stands for Traumatic Brain Injury. There is plenty of research

on how TBI occurs and how it debilitates the brain, but there are few strategies available

to parents and educators to help a child with TBI re-learn to function. For the purpose of

this project, the following questions are asked:

1. What is TBI and how does it affect the brain?

2. What strategies are there for Teachers in the area of memory loss?

3. What strategies are there for Reading Comprehension?

4. What strategies are there for Math Intervention?

The review of the literature is from peer-reviewed, research-based documentation, as well

as government-sponsored reports to demonstrate truth in the findings of this review.

What is TBI and how does it affect the brain?

“A TBI results from a blow or jolt to the head or a penetrating head injury that

disrupts the function of the brain”(Polito,Thompson & Defina (2010, p504) In a Report

to Congress(http://www.cdc.gov/ncipc/pub-res/mtbi/mtbireport.pdf ) in 2003 states the

following:

According to existing data, more than 1.5 million people experience a traumatic

brain injury (TBI) each year in the United States. Of them, as many as 75 percent

sustain a mild traumatic brain injury—or MTBI. These injuries may cause long-

term or permanent impairments and disabilities. Many people with MTBI have

difficulty returning to routine, daily activities and may be unable to return to work


or many weeks or months. In addition to the human toll of these injuries, MTBI

costs the nation nearly $17 billion each year.(p 1)

Medscape states that “Traumatic brain injury (TBI) is a nondegenerative, noncongenital

insult to the brain from an external mechanical force, possibly leading to permanent or

temporary impairment of cognitive, physical, and psychosocial functions, with an

associated diminished or altered state of consciousness.” American Congress of

Rehabilitation Medicine defines mild head injury as "a traumatically induced physiologic

disruption of brain function, as manifested by one of the following:

• Any period of loss of consciousness (LOC),

• Any loss of memory for events immediately before or after the accident,

• Any alteration in mental state at the time of the accident,

• Focal neurologic deficits, which may or may not be transient."

There is another type of TBI called Hypoxic-Anoxic Brain Injury HAI. We know that

the brain is dependent on oxygen. HAI is the deprival of oxygen to the brain as is stated

by the Los Angeles Caregiver resource center. “the term hypoxic means partial lack.

Other HAI injuries are due to a complete lack of oxygen; the term anoxic means total

lack. The greater the loss of oxygen, the more wide-spread and serious the injury will

be.” (CDMC, 2004,p. 1) Research resulted in another question, what happens to the

brain? What do we need to look at or know? As an Educator, knowledge is power, and

understanding how the brain reacts to this injury is just as important as well as, how the

family, school, and student will react. The Traumatic Brain injury In the United States

Report to Congress 1999 (sums it up perfectly:


For the estimated 5.3 million Americans who live with a TBI-related disability,

the financial cost is only part of the burden. The long-term impairments and

disabilities associated with TBI are grave and the full human cost is incalculable.

Yet because these disabilities are not readily apparent to the public--unlike a

broken leg, for example--TBI is referred to as the invisible epidemic. These

disabilities, arising from cognitive, emotional, sensory, and motor impairments,

often permanently alter a person's vocational aspirations and have profound

effects on social and family relationships. For many people they feel that they

have lost the person they once knew. (p 2)

What happens to the person? According to Polito, Thompson and Defina ( 2010) in the

article, A review of the International Brain Research Foundation novel approach to mild

traumatic brain injury presented at the International Conference on Behavioral Health

and Traumatic Brain Injury:

Psychological changes associated with TBI often include “executive

dysfunction,” which may be seen clinically as disinhibition, (sic) inappropriate

behavior, impulsivity, emotional lability, (sic) poor judgment, lack of insight, and

regressed social and occupational functioning. Neurocognitive impairments

usually involve a combination of problems with verbal and nonverbal working

memory, verbal ﬂuency, attentional (sic) mechanisms, visual-motor processing

speed, planning and organizing, a shifting conitive(sic) set, and personality

changes. (p 505)

With HAI’s the problems can be cognitive and physical. Los Angeles Caregiver

Resource Center states the following can be the results of the damage:


• Short-term memory loss

• Decline in Executive functions

• Difficulty with words

• Visual Disturbances

• Ataxia (lack of coordination)

• Spasticity Jerky notions

• Quadriparesis (weaknees of the arms and legs)

• In addition there can be depress, irritability, and an inability to focus or

concentrate.

As an educator, understanding the brain, and understanding the results of this injury, are

the first step in designing a strategy to assist the student with TBI to overcome their

struggles. (p 2)

In 2000 the CDC upon the request of the medical world issued the CDC Injury

Prevention report on TBI and Assessing children some of the recommendations, which

follow along with the purpose of this project summarized the following

There is a lack of communication for educational service that are appropriate, and

many times the students are identified as LD (learning disability) vs TBI. Caregivers

lack the awareness of available services, and many times the actual knowledge as to the

results of the injury; and how damaging it can be is not presented. The article points to

the need for educators to be educated prior to assessing the student, and gives

recommendations of many different assessment tools for the school to use. (p 234-235)


Understanding the brain of a student with TBI, as an educator, is like

understanding a road map. The student has always gotten from point A to point B by

taking a direct route. Now the brain needs to find an additional route to get to the same

place, and that is very difficult, and frustrating. Studies have shown since this is called

the silent disability there are so many issues that are not academia related. Krach,

Gormley Jr., & Ward. (2009). Chapter 10: Traumatic Brain Injury. In , Pediatric

Rehabilitation: Principles & Practice :

Too often, children with TBI remain underserved and, in some cases, forgotten.

Sometimes educators are unaware the child had a previous TBI, or if their

academic performance on achievement tests was within the average or acceptable

range, they are deemed to be unaffected by the brain injury. Their diagnosis is

forgotten until they have failed academically. (p 248)

TBI is real and incidents are increasing. Educators, parents and students need effective,

easily accessible tools.

What strategies are there for Teachers in the area of memory loss?

Memory loss is one of the biggest concerns for students with TBI. According to

the article, Pediatric Rehabilitation: Principles & Practice

Memory impairment is another common area of concern after pediatric TBI.

Typically, the memory impairment that is seen is for the formation of new

memories as opposed to long-term memory. This has significant implications for

a child’s ability to learn new information. As observed in other areas, severity

of memory impairment appears to be related to the overall severity of injury.

Impairment is seen in both immediate and delayed recall in severe TBI. (p 239)


What are some of the researched based strategies for memory loss?

The way the target memory task is presented – visually or orally – affects

memory. The ‘picture superiority effect’ (Paivio, 1971) states that pictures are

recalled better than words because they are encoded, and stored in both verbal and

non-verbal codes. Item storage in image memory is more durable than in verbal

memory. Furthermore, while processing visual information, participants develop

the meaning behind pictorial stimuli more than words (Craik & Lockhart, 1972)

Research of many strategies and areas of concern revealed in the article, Explicit memory

among individuals with mild and moderate intellectual disability: educational

implications by Lifshitz, Shtein, Weiss, & Svisrsky (2011) that one of the best ways to

work with memory is to “utilize(sic) multimedia. When teaching the aforementioned

material, use multimedia devices such as the video and computer. These media do not

require the use of expressive language and provide feedback after learning. Integrate the

learners’ own photographs into stimulus materials. (p116)

As an educator, multimedia is used every day. Students have never been without

cell phones, computers, and now iPADS. Simple games on the computer like

concentration, Sudoku, and crossword puzzles can stimulate that short-term and long-

term memory. We know the brain is a muscle we need to exercise it.

What strategies are there for Reading Comprehension?

As stated above Metacognition Strategies is the preferred strategy for teaching

reading comprehension. What are some of those strategies? How should they be

applied? According to Othman, Darussalam, Brunei (2010)


Metacognition is a concept that has been used to refer to the diversity of

epistemology process. Epistemology is a theory on knowledge particularly the

one related to critical research on method and scope of knowledge. In terms of its

concept, metacognition basically means cognition about cognition that refers to

second-order cognitions; thoughts about thoughts; knowledge about knowledge;

and reflections about actions. (p 457-458)

There are many comprehensive strategies. Which one works and which one does not?

Each child is different; so are the strategies that a teacher should use. For all teachers it is

extremely valuable to have a firm grasp of all reading comprehensive, research-based

strategies that are effective have been presented. The following according to Kracch,

Paivio, Yahya, in the CDC injury prevent report(2010)identifies the best Comprehension

Strategies Used by Teachers are Story Retelling, Think-Alouds, Question Answer,

Relationships, KWL Charts, Story Maps, Graphic Organizers. (p 368)

Teachers need to be creative, use checklists, try various methods, and think

outside the box. There are many different strategies that are out in the educational world

the list above are research-based and they are the foundation. As in, all situations,

borrow and utilize other sources ask other teacher, search the internet, read journals, go to

seminars. Find a strategy that works and use it. Consistency is very important, once your

find a strategy that works use it and if the student suffering from memory loss, repetition

is key.

What strategies are there for Math Intervention?

Mathematics is an issue across all boundaries; according to the article Using an

Intelligent Tutor and Math Fluency Training to Improve Math Performance stated that:


results of the Third International Mathematics and Science Study (TIMSS)

involving a half-million students showed that U.S. fourth-graders perform poorly,

middle school students worse and high school students are unable to compete. In

the 2006 Program for International Student Assessment, US students ranked 17th

out of 30 in the science assessment and 24th out of 30 in math. (p 136)

Students with TBI, suffering from memory loss, and other damages, may have been

good, exceptional or poor in math may now be completely different. It has also be

determined that “Students with LD characteristically are poor problem solvers. They

typically lack knowledge of problem-solving processes, particularly those necessary for

representing problems and, therefore, need to be taught those processes explicitly and

shown how to apply them when solving math word problems (Montague & Applegate,

1993). Today math intervention is not just for students with disabilities.

What are the best strategies for Math intervention? We know that repetition is

important in math to develop those skills that are the basics of math. “Automatic skills,

which are only acquired after considerable practice, consume little cognitive capacity and

allow the possibility of performing multiple tasks relevant to the problem at hand

simultaneously.” (Arroyo, Royer, Woolf, 2011, p 138). According to the article by

Louie, Brodesky, Brett, Yang, Tan, & Regional Educational Laboratory Northeast &

Islands (2008). Math Education Practices for Students with Disabilities and Other

Struggling Learners, there is no one method for students with disabilities, a summary of

what they recommended is as follows:

• Graphic organizers

• Computer games


• Manipulative, hands on math

• Peer teaching (p 8)

Response to Intervention (RTI) is another strategy for Mathematics.

The literature presented is from peer-reviewed, research- based documentation, as

well as government-sponsored reports. This literature was presented to demonstrate truth

in the findings of this review. These results are explored and applied to the interactive

website project. Each of the pages of the website addresses one of the questions:

What is TBI and how does it affect the brain?

What strategies are there for Teachers in the area of memory loss?

What strategies are there for Reading Comprehension?

What strategies are there for Math Intervention?

Summary

The website www.effectiveteachingtbi.org will answer the above questions and

will also demonstrate for teachers an effective strategy that worked for this educator. The

purpose of the website is to provide information and real life strategies for this growing

need.


Chapter 3

Introduction

There is plenty of research on how TBI occurs and how it debilitates the brain, but

there are few strategies available to parents and educators, to help a child with TBI re-

learn to function. Teachers need practical teaching strategies. This project provides an

interactive website to educate parents, teachers and people who suffer from TBI. In

addition, this website gives examples of teaching strategies. The strategy is presented in

video representation.

Background of project

During the past year, this teacher has worked with several students in high school

that have suffered TBI. One student was kicked in the head by another player during a

soccer game. One student attempted suicide by hanging, and suffered an Hypoxic-

Anoxic Brain Injury (HAI). Each student had severe memory loss. Each student had lost

many of their basic cognitive functions. For example, one student was an excellent math

student and now struggled with multiplication tables. The other student, an avid writer,

now struggled to write one paragraph. It is our responsibility, as special educators, to give

these students the tools they need to be successful.

Components of the project

There is a lot of research on what TBI is; however, as it is an injury that cannot be

seen (like a broken leg) each person is affected differently, as an educator, we must find a

way to re-route the brain. Reading about different strategies is a great start but how do

you apply the strategies what do they look like. This is the reason this educator made this


website. This website gives information on the three areas of need, English Language

Arts (ELA), Mathematics, and Memory Retention.

The home page on the website gives general information about TBI. Pages two,

three and four of the website have actual teaching strategies for each area, ELA

Mathematics, and Memory Retention, and one life skill strategy. The final page has a list

of websites and links (Appendix B). There is also a survey page for the informal

feedback.

The students with TBI that are working with this special education teacher will

determine the strategies used on the website “The concepts of teacher effectiveness and

research-based instructional strategies combine to form a foundation that results in

changes in teaching.” (Fabry, 2010, p.24). Research based strategies are the only

strategies presented on the website.

Methodology and project design

After many months of research and utilizing several research-based strategies, the

ones that were most effective for the students were chosen for the website the choice of

one strategy over another is not to recommend, but to demonstrate, possible strategies.

The participants on the videos are not the students in the research of this project,

but paid student actors. The videos (Youtube) describe the strategy and demonstrate the

technique implementation. In addition, a PDF of the lesson is on the website.

An informal survey of the website and the effectiveness will give these educator

ideas for future videos, strategies and lessons. As stated, this is an interactive website,

research will be on going, and as more information, links and strategies are used, the

website will be updated.


Summary

The strategies that were tried were research based strategies. The strategies that

were chosen were the strategies that worked with the students. The choice was not an

evaluation of which strategy was better or worse but which one worked.


Chapter 4

Evaluation of Project

Educators need a place to get information on effective strategies, but more

importantly to see a demonstration of what the strategy looks like. This project will

provide educators, parents, and persons with TBI the information, and strategies as well

as the modeling of those strategies. This website will provide information, papers, and

links to other websites. The hope is that these demonstrated strategies may relieve

frustration and will help to improve the student’s physical and emotional wellbeing.

This web site design is a tool for multiple users. Teachers may be the main target and

user of this information but parents will seek strategies that they can use to support their

children with TBI. People with TBI will themselves research strategies to re-gain their

lives .

The internet provides a median for this information. As an interactive website

the continual monitoring of the information and strategies are a vital part of the

evaluation of the project. The determination of this project and effectiveness of the

website will be the informal evaluation.

Limitations to the website and plans for future expansion

The largest limitation to the website is time. The website is now up and running

www.effectiveteachingtbi.org. The videos on the website require a written consent to be

videoed as the participants are minors; however, they are not my students and are used as

actors only. In addition, the use of a professional cameraperson was used and the

information uploaded to the website.


Research for this project in ongoing and as an interactive website will be updated

as needed. The design of the website is complete. The rest of the project is on going

including:

• Determine the research strategies for each page of the website

• Monthly new research strategies

• Review informal evaluations from the information link-postings

The future plan depends on funding and reactions to the site. This is a work in

progress and will be updated based upon research and implementation of the strategies.

The site officially went up on October 12, 2012, and has had over 100 hits in less than a

month. The postings as of 10-30-2012 are as follows

In favor of the site—13 postings

Suggestions for the site-1 posting

Solicitation for other things-6 postings

Spam-5 postings

Conclusions

As an educator, understanding the brain of a student with TBI, is like

understanding a road map. The student has always gotten from point A to point B by

taking a direct route. Now the brain needs to find an additional route to get to the same

place, and that is very difficult, and frustrating. This website will assist teachers, parents,

and persons with TBI, by giving them tools and information. Arroyos-Jurado, Paulsen,

Ehly and Max stated it best as an educator “Not only do educators need to draw on

student’s strengths, they also need to come up with novel approaches to teaching learning


strategies.” (2001,p.137). This project is based on this statement. Each of the strategies

that are used and will be used are novel approaches for each individual person. This

project’s goal is to assist the student, parent and teacher to be successful in educating

themselves and others and to assist all persons who experience TBI.


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http://www.caregiver.org/caregiver/jsp/print_friendly.jsp?nodeid=1822 retrived on

4/14/2012

http://www.brainandspinalcord.org/traumatic-brain-injury-types/anoxic-brain-

injury/index.html retrived on 4/12/2012

http://www.netc.org/focus/strategies/ retrieved on 3/20/2012


http://emedicine.medscape.com/article/326510-overview retrieved on 3/20/2012

http://www.acrm.org/ retrieved on 4/12/2012

http://www.cdc.gov/ncipc/pub-res/mtbi/mtbireport.pdf retrieved on 4/14/2012

http://effectiveteachingtbi.org/


Appendix

Website: www.effectiveteachingtbi.org

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