School Re-Entry After Brain Injury: A Guide for School Nurses

1. School Re-Entry After Brain Injury:A Guide for School Nurses Sarah H. Powell, M.Ed. CCC-SLP, CBIS Roger C. Peace Rehabilitation Hospital Brain Injury Education Initiative

2. Navigating Through Brain Injury • Disguised as a low incidence disability, brain injury is occurring and systematic change in service delivery is crucial to meet the needs of our students.

3. What is the Brain Injury Education Initiative? • The Outpatient Brain Injury Program of Roger C. Peace Rehabilitation Hospital, part of the Greenville Hospital System, was awarded a grant through the SC Developmental Disabilities Council aimed at improving the effectiveness of the school re-entry process following Brain Injury. • The "Brain Injury Education Initiative" provides an opportunity for research and training that provides assistance to students, their families, and educators.

4. Did you know…. • Over 1000 school and college aged South Carolina residents are discharged from hospitals secondary to TBI each year. • The single most important factor for successful school re-entry is the communication between schools and hospitals. • 98% of health recovery happens outside the hospital. • This epidemic is the leading cause of death and disability in children and young adults.

5. Did you know… • With 1144 public schools and 54 colleges and technical schools in SC, it is difficult to achieve and maintain the level of training needed for all education professionals who might have a student with significant brain injury related disability. • Because each brain injury is different, there is no one teaching program that will apply to all students. Ongoing education is a must!

6. Why do we need the “Brain Injury Education Initiative?” • Google “Brain Injury and School” and an astounding 14,700,000 hits are returned. “Brain Injury and Study Skills” returned a whopping 818,000. (That’s 110,000 more than this time last year!) The shear volume can be overwhelming to a new family, student or educator faced with brain injury. • The combination of population demographics (potentially any child, any city) and the fact that most children return to regular classrooms results in the possibility of any nurse in SC having a student with TBI in their school.

7. TBI Educators Training Assessment • Over 100 educators around SC were surveyed • Only 10.9% of educators felt like there was adequate communication between medical professionals and the school. • A little over half of educators felt like there was good communication between themselves and parents. • Only 40% of educators felt like information about a student with BI was being passed along at the school level.

8. Family Survey’s Stated… • 80% of parents felt like they’d been given adequate info about BI for their return to school. • Over 85% felt like their child was equipped with study strategies or tools needed to be successful in the classroom. • 63% felt like there was adequate communication between medical professionals and school. • Only 44% felt like the school system was prepared for their child’s return to school. • Less than 20% felt the teachers demonstrated adequate knowledge about brain injury.

9. TBI Educators Training Assessment • 44% of teachers felt comfortable with their knowledge concerning TBI. • 37% of teachers felt they could screen students for BI who were performing below expectations. • When asked about treating, managing, and teaching those with brain injury, 41% of teachers are comfortable. • But when asked if their school or district offers education around brain injury, only 16% said yes, while 58% said no.

10. Parents… “I need to be careful how I say this…it’s almost like it would’ve been better if the injury were severe enough that we would’ve had to have gotten help. With TBI, the moderate to mild, it’s invisible. People don’t see it and then people don’t get the help they need.” ~Parent

11. Tag… YOU’RE IT!

12. Goals • Understanding Traumatic Brain Injury • Identification and Assessment • Advocacy and Your Role • Resources

13. 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.

14. 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.

15. SC Special Ed Law states… • Traumatic Brain Injury means 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 student’s educational performance. • The term applies to open or closed head injuries resulting in impairments in one or more areas, such as cognition; language; memory; attention; reasoning; abstract thinking; judgment; problem-solving; sensory, perceptual, and motor abilities; psychosocial behavior; physical functions; information processing; and speech. • The term does not apply to brain injuries that are congenital or degenerative, or to brain injuries induced by birth trauma.

16. Types of Brain Injury

17. Examples • Traumatic Brain Injury • Stroke • Brain Tumor • Seizure Disorder • Anoxic event • Infectious disease such as Encephalitis

18. When a Brain is Injured… Primary Effects • A coup injury is caused by the impact where the blow occurs or the head strikes. • A contrecoup injury is the result of further damage as the brain rebounds and collides with the side of the skull that is opposite the initial site of impact (the coup). • Acceleration/deceleration are the rapid movements of the brain forward and backward. For example, this can happen during a car crash, during a bicycle fall when the head hits the ground, or when a baby is shaken. • Shearing/rotation occurs as the twisting and rotation of the brain damages blood vessels and nerve fibers. Permanent diffuse damage may result from even a mild injury.

19. When a Brain is Injured… Secondary effects • Occur after the initial injury and can complicate the severity of the brain injury. • The most common secondary effect is increased intracranial pressure. • This causes more blood to build in the vessels and can result in tissue death.

20. Parts of the Brain

21. Parts of the Brain

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

23. 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

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

25. 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

26. 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

27. 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

28. 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

29. 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)

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

31. 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

32. Severe Traumatic Brain Injury: Treatment • Short to very long stays in ICU/PICU/ Neuro ICU’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

33. Typical Medical Course for a Student with a Moderate/Severe TBI Emergency room Regional trauma center if necessary Surgery if necessary Acute care setting (hospital) Rehabilitation unit or center School

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

35. 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

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

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

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

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

40. 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

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

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

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

44. Irritability Impulsivity Disinhibition Perseveration Emotional Lability Insensitivity to social cues Low frustration tolerance Anxiety Withdrawal Egocentricity Denial of deficit/lack of insight Depression Peer conflict Sexuality concerns High risk behavior Emotional & Behavioral Problems

45. Most Common Emotional-Behavioral Problems: • Fragile Emotional Control • Poor Awareness • Impulsivity • “Just don’t get it”

46. 4 Facts about Identification • Each student will vary greatly, no 2 will be alike • Changes are unlikely to disappear fully over time • Negative consequences may not be seen immediately but emerge when developmental demands reveal problems • An injured brain is less likely to meet the increasingly complex tasks all children face as they get older

47. Misclassified or Missed Altogether • Poor transitional services between hospitals and schools • Timing of injury • Mild TBI slips thru the cracks • Traditional approaches to assessment fail to provide necessary insight into how cognitive deficits impact school • Special Ed for TBI vs. LD vs. ED looks different • Deficits are not always immediately apparent

48. How is TBI different from LD? • TBI is not “just a learning disability” • Students with TBI cannot be dealt with as if they have something similar • Although similar, the differences are important • The impairments are different, as are the implications for educators

49. TBI: How is it Different?

50. Information to Determine Needs • Obtain all medical information you can • Information about areas of functioning • Cognition and memory • Speech and language; communication • Sensory and perceptual abilities • Motor abilities • Psychosocial impairments • Physical functions/safety • Academic skills