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

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Presentation on theme: "School Re-Entry After Brain Injury: A Guide for School Nurses"— Presentation transcript:

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! Flexible schedule
A passion for learning and meeting the needs of students with medical conditions/disabilities

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 16

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 21

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 Typical early course 23 23

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 Medical contact? Family School experience 25 25

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 33

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
Seizures Fatigue Headaches Swallowing/Eating Self-care activities Medication issues

37 Most Common Physical Deficits:
Physical Endurance Mental Endurance Headaches

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

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

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

44 Emotional & Behavioral Problems
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

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?
LD ED Onset and Cause Sudden with blow to head and loss of consciousness Early/ unclear Slow/ unclear Functional Change Marked contrast between pre and post onset No before-after contrasts Changes emerge slowly Physical Disabilities Loss of balance, weakness, paralysis Poor coordination Unlikely Behavior Agitation, impulsive, restlessness, disinhibited Restlessness, impulsive Variable Emotions Labile, depression, anxious Prone to outbursts Reactions due to distortions of reality Academic Deficits Based on disrupted cognition Based on type of learning disability Not based on impaired cognition Difficulties with Learning Old info easier to recall than new info New learning can be linked with old learning

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

51 Challenges to Evaluation: Student Factors
Rapidly changing skills (especially during first 6-12 months) Communication, physical, sensory, motor, emotional, and behavioral difficulties may interfere with assessment Performance influenced by state and situation Problems may emerge later Medical instability Adverse effects of medication

52 Other Challenges to Evaluation
The family is in distress Initial assessment is conducted outside the school in a setting unlike the classroom Much assessment information is needed from other professionals Assessment requires IEP team coordination and planning

53 How can I gather more info?
Record review (school and medical) Direct observation (school or hospital) Student interview (if possible) Teachers/service provider interviews Criterion-referenced assessment Curriculum-based assessment Rating scales and checklists Neuropsychological assessment (if available) Identify cognitive strengths and weaknesses

54 Intervention Environment (space and time) Instruction and materials
School staff Peers Student Family Pharmacological 54

55 Most Common Physical Deficits:
Physical Endurance Mental Endurance Headaches

56 Endurance: Shuts down at certain times of the day
Primary Middle School High School Shuts down at certain times of the day More likely argumentative Slows down The slow blink When assessing, observation level Anne to do Whining Low frustration tolerance Conflict with peers 56 56

57 Mental Endurance Environment Instruction School staff/ Peers Student
Preferential seating, fewer transitions, less core academic classes, shorten school day, part time or homebound instruction Instruction Slow the pace of instruction, reduce the components, provide repetition, watch for frustration School staff/ Peers Check on other class demands, identify patterns of fatigue or inattention, offer breaks; work in pairs or groups Student Take rest breaks before fatigue starts, eat healthy snacks, exercise, speak up if tired Family Educate on importance of sleep and routine Medical Adjust medications, look for depression, seizures, attention problems; side effects of current meds

58 Headaches Primary Middle School High School Most often able to be more specific, but may under or overgeneralize effect Increase with mental/physical exertion When assessing, observation level Anne to do Vague complaints 58 58

59 Headaches Environment Instruction School staff/ Peers Student Family
Allow student to leave and go to comfortable place to lay down in quiet and darkness; limit noise in classroom Instruction Break components down, slow pace of instruction, Provide rest breaks, use intermittent teaching to avoid exacerbation School staff/ Peers Educate other staff and peers; Encourage low stimulation by other students Student Encourage student to speak up at first sign of headache Family Alert family; Keep journal and data Medical Explore medications, consult with family or rehab doctor; side effects of current medications; screen vision

60 Advocacy…What is it? What is your role?
"Advocacy" can mean many things, but in general, it refers to taking action. Advocacy simply involves speaking and acting on behalf of yourself or others.

61 The School Nurse Advocate for the Student
Coordination of Health Care Issues and Services Assistance to Educators and Parents by Sharing your Knowledge of Brain Injury Prevention

62 What can you do for the student?
Understand and watch for signs and symptoms of brain injury Recognize when to refer and who to refer to Be the one to link injury with problems in the classroom Listen and offer understanding Help with transitions Educate student and his/her peers Consider Health Related Issues Safety precautions, seizures, headaches, pain, endurance, fatigue, medication, visual issues

63 What can you do for the team?
Coordinate Obtain and interpret medical records Help measure milestones Consult with school psychologist, guidance counselor, and resource teacher Provide assistance deciphering between disorders Follow Up and Follow Through…the long term effects of TBI Intervene…accident=headaches=TBI The long term impact of brain injury

64 !!! Remember You might be the one person on staff that has the understanding to associate recent changes in a student’s behavior with a possible brain injury

65 How can you Educate? Educate school staff and auxiliary staff
The importance of rest breaks, snacks, temperature, orientation, safety Provide in-services/coordinate with BIA Communicate with family regularly and set the expectation for them to be a part of the team

66 How can you Prevent? Educate Your participation with other programs
Drug and alcohol abuse Drivers education Helmets and Safety Sports and concussions Violence prevention

67 Resources…at your fingertips

68 Brain Injury Navigator
is a South Carolina website aimed at providing up to date information and resources to educators, families and students regarding brain injury and school re-entry. The BI Navigator will allow interested parties to more conveniently and directly access support materials.

69 Why BI Nav? Brain Injury Navigator is our attempt at solving part of the communication problem. Brain Injury Navigator is that Educational Resource which is highly needed to filter out information for our families, students, and teachers…to make SC resources easier to find and to create a network for those interested in brain injury.





74 In addition… Contact the Brain Injury Association
Become a Certified Brain Injury Specialist Form a “TBI team” Check out a tool kit Consider your own continuing education

75 Where? Aiken County School District
Center for Disability Resources Library at USC Charleston County School District Dorchester County School District 2 Greenville County School District Horry County School District Peace Rehabilitation Center Richland County School District 2 South Carolina Brain Injury Association Spartanburg County School District 5 York County School District 4

76 Talk about brain injury
Helps change people’s attitudes Keeps everyone on the same page Provides education Flushes out myths versus facts Provides opportunities for brainstorming Allows for sharing and giving examples Gives a chance to say thank you

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