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RCLD Criteria for Outside Documentation: Acquired/Traumatic Brain Injury

Brain injury can result from external trauma, such as a closed head or an object penetration injury, or internal trauma, such as a cerebral vascular accident or tumor. ABI can cause physical, cognitive, emotional, social, and vocational changes that can affect an individual for a short period of time or permanently. Depending on the location and extent of the injury, symptoms can vary widely. Understanding functional changes after an injury and resulting implications for education are more important than only knowing the cause or type of injury.

Specific documentation guidelines for ABI include the following:

  • General documentation guidelines listed in Appendix D.
  • Documentation of date of occurrence/diagnosis and the nature of the neurological illness or traumatic event that resulted in brain injury.
  • Depending upon the functional domains impacted by the injury, assessments of cognitive and academic deficits and strengths, psychosocial-emotional functioning, and/or motor/sensory abilities relevant to academic functioning may be essential components of documentation of the impact of an acquired brain injury for an individual student.
  • Impairments following an acquired brain injury may change rapidly in the weeks and months after the injury, and a more stable picture of residual weaknesses may not be apparent for 1-2 years after an injury. More recent documentation may be necessary to adequately assess the student’s current accommodation needs.
  • Cognitive and academic processing weaknesses and strengths must be evident on multiple measures and not based on a single discrepant score:

    • Academic Achievement

      • Reading (decoding, fluency, and comprehension)
      • Mathematics (calculations, math fluency, applied reasoning)
      • Written Language (spelling, fluency, written expression)
    • Cognitive Processing Skills

      • Attention
      • Executive Functions
      • Fluency/Automaticity
      • Memory/Learning
      • Oral Language
      • Phonological/Orthographic Processing
      • Visual-Motor
      • Visual-Perceptual/Visual-Spatial

For system level accommodations (CPC foreign language substitution or Regents' Test accommodations), this documentation must be evaluated and approved by a Regents Center for Learning Disorders.

Taken from the USG Disabiltiy Documentation for Acquired Brain Injury.

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