Presentation on theme: "School Re-Entry After Brain Injury: A Guide for School Nurses"— Presentation transcript:
1School Re-Entry After Brain Injury: A Guide for School Nurses Sarah H. Powell, M.Ed. CCC-SLP, CBISRoger C. Peace Rehabilitation HospitalBrain Injury Education Initiative
2Navigating 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.
3What 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.
4Did 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.
5Did 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!
6Why 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.
7TBI Educators Training Assessment Over 100 educators around SC were surveyedOnly 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.
8Family 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.
9TBI 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.
10Parents…“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
11Tag… YOU’RE IT! Flexible schedule A passion for learning and meeting the needs of students with medical conditions/disabilities
12Goals Understanding Traumatic Brain Injury Identification and AssessmentAdvocacy and Your RoleResources
13Disguised 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, and1.365 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.
14Incidence 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.
15SC 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.
17Examples Traumatic Brain Injury Stroke Brain Tumor Seizure Disorder Anoxic eventInfectious disease such as Encephalitis
18When a Brain is Injured… Primary EffectsA 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.
19When a Brain is Injured… Secondary effectsOccur 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.
23Mild Traumatic Brain Injury: AKA Concussion - Definition Any period of loss of consciousnessAny loss of memory for events immediately before or after the accidentAny alternation in mental state at the time of accidentPosttraumatic amnesia is no greater than 24 hoursSigns of concussion nausea and vomiting, headache, fatigue, dizzinessTypical early course2323
24Concussion: Sports related injuries Immediate Presentation:Delayed effects:
25Mild Traumatic Brain Injury: Typical Early Recovery Common effectsHeadachesLethargyDizzinessSensory hypersensitivitiesPoor concentrationCourseAbout 80% uncomplicated mild TBI’s fully recovery by 3 monthsMedical contact?FamilySchoolexperience2525
26Mild Traumatic Brain Injury: Treatment Estimated 80% of concussions are not treatedMost often seen in the emergency room or by pediatrician and sent homeOut of school perhaps a day or two, up to a couple weeks
27Moderate Traumatic Brain Injury: Definition Coma less than 24 hours durationPost traumatic amnesia 1-24 hoursNeurological signs of brain traumaTissue damageBleeding
28Moderate Traumatic Brain Injury Typical Early Recovery Common effectsThose seen in Mild TBI, but of greater severity, frequency and longer durationHigher risk of focal deficitsHigher risk of motor deficitsCourseGenerally 3 to 6 monthsGreater risk of long term deficits after initial recovery
29Moderate Traumatic Brain Injury: Treatment Most often seen in the emergency room or by pediatrician and sent homeOccasionally hospitalized on an acute care medical unit for days to a couple weeksRarely receive inpatient rehabilitationMore frequently receive outpatient therapies (most often if there is a deficit in physical functioning)
30Severe Traumatic Brain Injury: Definition Coma more than 24 hoursPost Traumatic Amnesia more than 1 day
31Severe Traumatic Brain Injury Typical Early Recovery Common effectsAttention-executive, memory deficits are commonHigh risk of focal processing deficitsHigh risk of motor deficitsCourseGenerally 6+ monthsOver a 1/3rd classified as disabled after initial recovery period
32Severe Traumatic Brain Injury: Treatment Short to very long stays in ICU/PICU/ Neuro ICU’sMore likely to get inpatient rehabilitation, but more frequently seen by therapists in an acute medical care settingAverage inpatient rehabilitation stays are 2 to 4 weeksThe younger they are the less likely referred to inpatient rehabilitation and the quicker they are discharged homeMost likely to be referred to outpatient therapy
33Typical Medical Course for a Student with a Moderate/Severe TBI Emergency roomRegional trauma center if necessarySurgery if necessaryAcute care setting (hospital)Rehabilitation unit or centerSchool33
35Common Problems of Students with TBI Anticipating these difficulties can facilitate successful re-entry to schoolProblems can be physical/medical, cognitive, sensory, motor, social, emotional, and behavioral
41Most Common Sensory/ Perceptual Issues: OVERSTIMULATION!Double VisionNeglect / InattentionHypersensitivities
42Cognitive-Communication Problems Executive functionsMemoryAttentionConcentrationInformation processingSequencingProblem solvingComprehension of abstract languageWord retrievalExpressive language organizationPragmatics
43Most Common Cognitive-Communication Deficits: Slowed Processing SpeedIntolerance of ComplexityAttentionMemory
44Emotional & Behavioral Problems IrritabilityImpulsivityDisinhibitionPerseverationEmotional LabilityInsensitivity to social cuesLow frustration toleranceAnxietyWithdrawalEgocentricityDenial of deficit/lack of insightDepressionPeer conflictSexuality concernsHigh risk behavior
45Most Common Emotional-Behavioral Problems: Fragile Emotional ControlPoor AwarenessImpulsivity“Just don’t get it”
464 Facts about Identification Each student will vary greatly, no 2 will be alikeChanges are unlikely to disappear fully over timeNegative consequences may not be seen immediately but emerge when developmental demands reveal problemsAn injured brain is less likely to meet the increasingly complex tasks all children face as they get older
47Misclassified or Missed Altogether Poor transitional services between hospitals and schoolsTiming of injuryMild TBI slips thru the cracksTraditional approaches to assessment fail to provide necessary insight into how cognitive deficits impact schoolSpecial Ed for TBI vs. LD vs. ED looks differentDeficits are not always immediately apparent
48How is TBI different from LD? TBI is not “just a learning disability”Students with TBI cannot be dealt with as if they have something similarAlthough similar, the differences are importantThe impairments are different, as are the implications for educators
49TBI: How is it Different? LDEDOnset and CauseSudden with blow to head and loss of consciousnessEarly/ unclearSlow/ unclearFunctionalChangeMarked contrast between pre and post onsetNo before-after contrastsChanges emerge slowlyPhysical DisabilitiesLoss of balance, weakness, paralysisPoor coordinationUnlikelyBehaviorAgitation, impulsive, restlessness, disinhibitedRestlessness, impulsiveVariableEmotionsLabile, depression, anxiousProne to outburstsReactions due to distortions of realityAcademic DeficitsBased on disrupted cognitionBased on type of learning disabilityNot based on impaired cognitionDifficulties with LearningOld info easier to recall than new infoNew learning can be linked with old learning
50Information to Determine Needs Obtain all medical information you canInformation about areas of functioningCognition and memorySpeech and language; communicationSensory and perceptual abilitiesMotor abilitiesPsychosocial impairmentsPhysical functions/safetyAcademic skills
51Challenges to Evaluation: Student Factors Rapidly changing skills (especially during first 6-12 months)Communication, physical, sensory, motor, emotional, and behavioral difficulties may interfere with assessmentPerformance influenced by state and situationProblems may emerge laterMedical instabilityAdverse effects of medication
52Other Challenges to Evaluation The family is in distressInitial assessment is conducted outside the school in a setting unlike the classroomMuch assessment information is needed from other professionalsAssessment requires IEP team coordination and planning
53How can I gather more info? Record review (school and medical)Direct observation (school or hospital)Student interview (if possible)Teachers/service provider interviewsCriterion-referenced assessmentCurriculum-based assessmentRating scales and checklistsNeuropsychological assessment (if available)Identify cognitive strengths and weaknesses
54Intervention Environment (space and time) Instruction and materials School staffPeersStudentFamilyPharmacological54
55Most Common Physical Deficits: Physical EnduranceMental EnduranceHeadaches
56Endurance: Shuts down at certain times of the day PrimaryMiddle SchoolHigh SchoolShuts down at certain times of the dayMore likely argumentativeSlows downThe slow blinkWhen assessing, observation levelAnne to doWhiningLow frustration toleranceConflict with peers5656
57Mental Endurance Environment Instruction School staff/ Peers Student Preferential seating, fewer transitions, less core academic classes, shorten school day, part time or homebound instructionInstructionSlow the pace of instruction, reduce the components, provide repetition, watch for frustrationSchool staff/PeersCheck on other class demands, identify patterns of fatigue or inattention, offer breaks; work in pairs or groupsStudentTake rest breaks before fatigue starts, eat healthy snacks, exercise, speak up if tiredFamilyEducate on importance of sleep and routineMedicalAdjust medications, look for depression, seizures, attention problems; side effects of current meds
58HeadachesPrimaryMiddle SchoolHigh SchoolMost often able to be more specific, but may under or overgeneralize effectIncrease with mental/physical exertionWhen assessing, observation levelAnne to doVague complaints5858
59Headaches 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 classroomInstructionBreak components down, slow pace of instruction,Provide rest breaks, use intermittent teaching to avoid exacerbationSchool staff/ PeersEducate other staff and peers; Encourage low stimulation by other studentsStudentEncourage student to speak up at first sign of headacheFamilyAlert family; Keep journal and dataMedicalExplore medications, consult with family or rehab doctor; side effects of current medications; screen vision
60Advocacy…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.
61The School Nurse Advocate for the Student Coordination of Health Care Issues and ServicesAssistance to Educators and Parents by Sharing your Knowledge of Brain InjuryPrevention
62What can you do for the student? Understand and watch for signs and symptoms of brain injuryRecognize when to refer and who to refer toBe the one to link injury with problems in the classroomListen and offer understandingHelp with transitionsEducate student and his/her peersConsider Health Related IssuesSafety precautions, seizures, headaches, pain, endurance, fatigue, medication, visual issues
63What can you do for the team? CoordinateObtain and interpret medical recordsHelp measure milestonesConsult with school psychologist, guidance counselor, and resource teacherProvide assistance deciphering between disordersFollow Up and Follow Through…the long term effects of TBIIntervene…accident=headaches=TBIThe long term impact of brain injury
64!!!RememberYou 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
65How can you Educate? Educate school staff and auxiliary staff The importance of rest breaks, snacks, temperature, orientation, safetyProvide in-services/coordinate with BIACommunicate with family regularly and set the expectation for them to be a part of the team
66How can you Prevent? Educate Your participation with other programs Drug and alcohol abuseDrivers educationHelmets and SafetySports and concussionsViolence prevention
67Resources…at your fingertips free.braininjurypartners.com
68Brain 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.
69Why 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.
74In addition… Contact the Brain Injury Association Become a Certified Brain Injury SpecialistForm a “TBI team”Check out a tool kitConsider your own continuing education
75Where? Aiken County School District Center for Disability Resources Library at USCCharleston County School DistrictDorchester County School District 2Greenville County School DistrictHorry County School DistrictPeace Rehabilitation CenterRichland County School District 2South Carolina Brain Injury AssociationSpartanburg County School District 5York County School District 4
76Talk about brain injury Helps change people’s attitudesKeeps everyone on the same pageProvides educationFlushes out myths versus factsProvides opportunities for brainstormingAllows for sharing and giving examplesGives a chance to say thank you