School Re-Entry after Traumatic Brain Injury: For Educators

1. School Re-Entry after Traumatic Brain Injury:For Educators Anne Bradley, Ph.D Sarah Powell, M.Ed. CCC-SLP Roger C. Peace Rehabilitation Hospital Traumatic Brain Injury Program

2. Goals • Understanding Traumatic Brain Injury • Returning to School • Identification and Assessment • Intervention and Classroom Accommodations • Advocacy and Resources

3. Preview of Section 1: Understanding Brain Injury • Appreciate the under-reported nature of TBI • Learn what a brain injury is • Learn how to identify the level of severity of a brain injury • Be able to generally predict the early course after injury

4. Disguised as a Low Incident Disability… • Each year, an estimated 1.7 million people sustain a TBI annually. Of them: • 52,000 die, • 275,000 are hospitalized, and • 1.365 million, nearly 80%, are treated and released from an emergency department. • The number of people with TBI who are not seen in an emergency department or who receive no care is unknown.

5. Incidence and Prevalence • Children aged 0 to 4 years, older adolescents aged 15 to 19 years, and adults aged 65 years and older are most likely to sustain a TBI.  • Almost half a million (473,947) emergency department visits for TBI are made annually by children aged 0 to 14 years. • Only 200 of every 100,000 cases go to the hospital.

6. Parts of the Brain

7. Definition of TBI • Acquired Brain Injury • Congenital and Perinatal Brain Injury • Traumatic Brain Injury • Open Head Injury • Closed Head Injury

8. Acquired Brain Injury • Brain Injury incurred after a period of normal development • Internal causes • External causes

9. Congenital and Perinatal Brain Injury • No period of normal development • Congenital- a condition a child is born with such as a chromosomal abnormality • Perinatal- a condition that develops around the time of birth such as a perinatal stroke

10. Traumatic Brain Injury • An acquired injury to the brain caused by an external physical force, resulting in total or partial functional disability or psychosocial impairment or both, that adversely affects a child’s educational performance.

11. Effects of Brain Injury • Injury to brain tissues at the site of damage • Shearing and tearing of neurons throughout the brain • Bleeding, swelling, and lack of oxygen to the brain • Possible coma

12. Severity of Brain Injury • Mild • Moderate • Severe

13. Mild Traumatic Brain Injury: AKA Concussion - Definition Any period of loss of consciousness Any loss of memory for events immediately before or after the accident Any alternation in mental state at the time of accident Posttraumatic amnesia is no greater than 24 hours Signs of concussion nausea and vomiting, headache, fatigue, dizziness

14. Concussion: Sports related injuries Immediate Presentation: Delayed effects:

15. Mild Traumatic Brain Injury:Typical Early Recovery • Common effects • Headaches • Lethargy • Dizziness • Sensory hypersensitivities • Poor concentration • Course • About 80% uncomplicated mild TBI’s fully recovery by 3 months

16. Mild Traumatic Brain Injury: Treatment Estimated 80% of concussions are not treated Most often seen in the emergency room or by pediatrician and sent home Out of school perhaps a day or two, up to a couple weeks

17. Moderate Traumatic Brain Injury: Definition Coma less than 24 hours duration Post traumatic amnesia 1-24 hours Neurological signs of brain trauma Tissue damage Bleeding

18. Moderate Traumatic Brain Injury Typical Early Recovery • Common effects • Those seen in Mild TBI, but of greater severity, frequency and longer duration • Higher risk of focal deficits • Higher risk of motor deficits • Course • Generally 3 to 6 months • Greater risk of long term deficits after initial recovery

19. Moderate Traumatic Brain Injury: Treatment Most often seen in the emergency room or by pediatrician and sent home Occasionally hospitalized on an acute care medical unit for days to a couple weeks Rarely receive inpatient rehabilitation More frequently receive outpatient therapies (most often if there is a deficit in physical functioning)

20. Severe Traumatic Brain Injury:Definition Coma more than 24 hours Post Traumatic Amnesia more than 1 day

21. Severe TBI sustained in a snowboarding accident: Recovery after a 2 month coma

22. Severe Traumatic Brain Injury Typical Early Recovery • Common effects • Attention-executive, memory deficits are common • High risk of focal processing deficits • High risk of motor deficits • Course • Generally 6+ months • Over a 1/3rd classified as disabled after initial recovery period

23. Severe Traumatic Brain Injury: Treatment • Short to very long stays in ICU/PICU/ NeuroICU’s • More likely to get inpatient rehabilitation, but more frequently seen by therapists in an acute medical care setting • Average inpatient rehabilitation stays are 2 to 4 weeks • The younger they are the less likely referred to inpatient rehabilitation and the quicker they are discharged home • Most likely to be referred to outpatient therapy

24. Review of Section 1: Understanding Brain Injury • Appreciate the under-reported nature of TBI • Learn what a brain injury is • Learn how to identify the level of severity of a brain injury • Be able to generally predict the early course after injury.

25. Preview of Section 2: Returning to School • Identify what actions need to be take to facilitate school re-entry after brain injury • Identify common physical and cognitive sequelae of brain injury • Assess issues that distinguish TBI from other diagnoses • Identify means by which the student’s needs can be assessed

26. The Process of School Re-entry:Who, When and How?

27. The Process of School Re-entry:Who

28. The Process of School Re-entry:When

29. The Process of School Re-entry:Moderate to Severe Brain Injury - How Medical Staff Families Identify a family and medical contact person to receive and provide information • Focus on the provision of medical care • Integrate the family into the patient’s care Educational Staff • Participate in their child’s medical care • Make their wishes known regarding visits and other contacts

30. The Process of School Re-entry:Moderate to Severe Brain Injury Medical Staff • Identify a school contact person • Provide updates on progress and needs • Provide information needed for the school to evaluate the student’s needs and form a reasonable school re-entry plan • Educate family and school staff

31. The Process of School Re-entry:Moderate to Severe Brain Injury Educational Staff • Request updates from medical contact person • Identify appropriate members of school re-entry team • Share information about student’s prior achievement and behavior with medical contact person • Educate medical staff regarding local education resources and procedures • Update others as needed

32. The Process of School Re-entry:Moderate to Severe Brain Injury Family • Consent to allow communication between school and medical staff • Facilitate contact between appropriate staff members • Participate in education provided by medical staff • Make wishes known regarding support needs

33. The Process of School Re-entry:Moderate to Severe Brain Injury Medical Staff • Inform family and school of discharge date • Provide discharge summaries • Provide summaries of treatment and recommendations • Complete appropriate paperwork to support recommendations (e.g., homebound, therapies at school, Early Childhood referral) • Maintain ongoing collaboration with schools as proceeds through outpatient therapies

34. The Process of School Re-entry:Moderate to Severe Brain Injury Educational Staff • Educate family about homebound, Section 504, and/or special education process • Refer for special education services if appropriate • Obtain medical records • Arrange for staff education (don’t forget homebound teachers) • Meet to determine if more evaluation is needed, and/or what is the appropriate immediate school plan for re-entry • Maintain ongoing collaboration with outpatient therapies

35. The Process of School Re-entry:Moderate to Severe Brain Injury Family • Participate in the school re-entry planning process on the medical and educational system sides • Make needs known regarding tolerance of risk • Make preferences known regarding priorities for the current school year • Maintain close communication with outpatient therapies and school regarding their child’s functioning

36. The Process of School Re-entry:Mild Brain Injury Medical Staff Families Identify a family and medical contact person to receive and provide information ? Educational Staff • Pursue appropriate medical care for their child

37. The Process of School Re-entry:Mild Brain Injury Medical Staff • Provide summary of findings and recommendations • Complete the necessary paperwork for referral for educational services • Consider referring for therapies and/or follow-up neuropsychological evaluation • If referred for ongoing therapies, identify contact person and maintain collaborative relationship with school

38. The Process of School Re-entry:Mild Brain Injury Educational Staff • Obtain medical records • Educate family about homebound, Section 504, and/or special education process • Consider homebound services versus part-time in-class attendance • Assess for Section 504 versus Special Education services • Arrange for staff education (don’t forget homebound teachers) • Plan to re-assess in 1-2 months • Maintain collaborative relationship with outpatient therapies if available

39. The Process of School Re-entry:Mild Brain Injury Family • Participate in the school re-entry planning process on the medical and educational system sides • Make needs known regarding tolerance of risk • Make preferences known regarding priorities for the current school year • Maintain close communication with outpatient therapies and school regarding their child’s functioning

40. TBI Students • Identification • Assessment/Evaluation

41. Which student has a TBI? • Can you tell?

42. Common Problems of Students with TBI • Anticipating these difficulties can facilitate successful re-entry to school • Problems can be physical/medical, cognitive, sensory, motor, social, emotional, and behavioral

43. Physical/Medical Problems • Problems • Seizures • Fatigue • Headaches • Swallowing/Eating • Self-care activities • Medication issues

44. Most Common Physical Deficits: • Physical Endurance • Mental Endurance • Headaches

45. Apraxia Ataxia Coordination problems Paresis or paralysis Orthopedic problems Spasticity Balance problems Impaired speed of movement Motor Problems

46. Most Common Motor Problems: • Balance • Fine Motor Dexterity • Motor Speed

47. Sensory/Perceptual Problems • Visual deficits • field cuts • tracking (moving and stationary objects) • spatial relationships • double vision (diplopia) • Neglect / Inattention • Auditory sensory changes • Tactile sensory changes

48. Most Common Sensory/Perceptual Issues: • OVERSTIMULATION! • Double Vision • Neglect / Inattention • Hypersensitivities

49. Executive functions Memory Attention Concentration Information processing Sequencing Problem solving Comprehension of abstract language Word retrieval Expressive language organization Pragmatics Cognitive-Communication Problems

50. Most Common Cognitive-Communication Deficits: • Slowed Processing Speed • Intolerance of Complexity • Attention • Memory