Recovering Brains:

1. Recovering Brains: Understanding Traumatic Brain Injury and the Supports Needed for Student Success Kim Leaf M.A. CCC- SLP

2. What’s in a name: • Traumatic brain injury (TBI)- occurs when a sudden, external, physical assault damages the brain. • Acquired Brain Injury (ABI)- a injury caused by an internal force such as a stroke, or disease impacting the brain.

3. Agenda

4. Demographics • 1.4 million a year in US • Incidence doubles for children 5-14 and 15-24. Children are more likely to survive than adults • Peaks for children and adolescence and early adulthood • 250 per 100,000: 80-90,000 sustain lifelong disability • 50,000 die annually • Currently 5.3 American’s are living with a TBI (2% of US pop.)

5. Who does TBI impact? • Males are 1.5X more likely than females to sustain a TBI • Highest incidence among age groups is 15 to 24, followed by 75 and older, then under age 4 • Leading cause of death and disability in children and young adults. • Family, Friends, and the Community

6. Types of TBI’s 2 type of Brain Injuries 1) Closed Head Injury- no break in the skull 2) Penetrating brain injury- a break in the skull

7. Causes of TBI • Most Common cause is Motor Vehicle Accidents (MVA’s). • Falls in Children (bicycles) and Elderly • Sporting Activity-post concussive syndrome (PCS) • Violence- Gunshots, Shaken Baby Syndrome, Domestic Violence

8. TBI’s and Children • Age 15-24 most likely to have TBI • Children’s brains are not little adult brains • TBI’s in childhood is the leading cause of death and long term disability • Rapid recovery may be misleading- recovery continues over years • Two phases immediate and latent recovery • Present both cognitive and psychiatric symptoms

9. Causes of ABI(Acquired Brain Injury) • Occurance during/after birth- lack of oxygen • Alcohol or drugs- slow onset • CVA’s, brain attacks/strokes aneurysms • Brain diseases: Tumors, AIDS, Alzheimer’s, MS • Lack of oxygen: Heart Attack

10. Severity of TBI • Mild • Brief or no loss of consciousness • Show signs of concussion • Moderate • Coma <24 hours • Neurological signs of brain trauma • Focal findings on EEG or CT Scan • Severe • Coma >24 hours

11. Post Concussive Syndrome (PSC)

12. Evaluation of Child Brain Injury • Primary injury: force of the injury, bruising, location and bleeding. • Secondary injury: hypoxia, ICP, seizures, cerebral swelling, axonal injury • Soft signs: less efficient thinking, problems getting along, executive function changes, moodiness • Severity: any LOC, duration • Morbidity increases with repetitive injury

13. Diffuse Axonal Injury (DAI) • DAI occurs when there is shearing (tearing) of the long connecting fibers (axons) as the brain shifts and rotates inside the skull. Microscopic changes not even seen in CT or MRI scans. (Coup-Contra Coup Injuries) • Primary brain injury-occurs at the time of impact. • Secondary BI- evolves over time (hrs-days) • http://www.youtube.com/watch?v=fY7J7bccNoU&feature=related

14. The Brain • The 3 pound universe, 2% of the bodies weight • Soft, jelly-like organ with billions of neural cross connections • 2 halves and 4 lobes and cerebellum • Floating in cerebrospinal fluid • Brain stem connects with rest of the body

15. Complications from TBI Changes in Skill Areas: • Cognitive • Physical • Sensory/Perceptual • Communication • Social • Emotional/Behavioral • Post Concussive Syndrome-PCS

16. Consequences: Cognitive Changes • Confusion • Decreased attention/concentration • Memory problems • Problem solving deficits • Judgment/ insight problems • Inability to understand abstract concepts • Decreased awareness of self/ others • Loss of sense of time/space • Trouble Multi-tasking • Difficulty with processing information

17. Physical consequences • Paralysis or weakness • Spasticity • Decreased balance, endurance • Delays in initiation, tremors • Swallowing problems • Poor coordination • Headaches • Fatigue

18. Perceptual/Sensory changes • Changes in vision, hearing, taste, smell, touch • Loss of sensation, heightened sensation • Left/right neglect • Difficulty understanding limbs in relation to body • Visual problems-double vision, acuity • Sensitivity to Light

19. Communication/ language • Difficulty speaking/ understanding (aphasia) • Difficulty choosing and saying words (anomia, apraxia, dysarthria) • Problems with speech articulation • Problems identifying objects, functions • Problems with reading, writing, math

20. Social Difficulties • Impaired social capacity-appears self centered • Difficulties in making and keeping friends • Difficulties in understanding social rules and subtle nuances in social interactions • Socially inappropriate acts and remarks

21. Regulatory Changes • Fatigue • Changes in sleep patterns, eating • Dizziness • Headaches • Bowel and bladder problems • Body temperature

22. Personality changes • Apathy • Decreased motivation • Emotional lability • Irritability • Anxiety and depression • Disinhibition

23. Challenges: Outcome Factors • Age at the time of injury • Severity and location of injury • Length of coma • Pre-injury personality, intelligence • Motivation to recover • Quickness and quality of hospital care • Family involvement and support network

24. Rehabilitation • Acute Rehabilitation- should start as soon as possible. From 3- 5 hours a day of active rehabilitation a day is optimal. Focus on achieving independent functioning. • Post-acute/ Community Based- the person no longer needs a hospital program. Focus on community living skills

25. The Recovery Process: Mild TBI • Mild Injury: Brief to No LOC, Concussion Symptoms (nausea, disorientation, lack of recall of incident, headache) • No treatment/ER visit, Observation, Screening, possible Outpatient services • Return to school: Observations, Accommodations based on need

26. Key Points for Return to School: Mild TBI • Cognitive changes may impact learning styles • TBI interrupts normal development • Needs may change rapidly • Effects may be delayed • Headache and fatigue common • Subtle changes may result in adjustment problems

27. Recovery: Moderate TBIs • LOC Less than 24 hours • ER, Outpatient/Inpatient Rehab care • Return to School: Work with hospital transition team, Specialized TBI Services, Accommodations and Modifications, possible IEP based on need.

28. Key Points for Return to School: Moderate TBI • Whole Person changes: Cognitive, Emotional, Physical • TBI interrupts normal development • Slower processing/thinking speed • Slower recovery rate than with mild TBI • But should improve more rapidly than student with Specific LD • Effects may be delayed • Adjustment issues are pronounced

29. Recovery: Severe TBIs • LOC more than 24 hours • ER, ICU, Extended hospitalization/rehab. • Return to School: Work with hospital transition team, Specialized TBI Services, Accommodations and Modifications, IEP based on need.

30. Key Points for Return to School: Severe TBI • Whole Person changes: Cognitive, Emotional, Physical • TBI interrupts normal development • Slower recovery rate • Effects may be delayed • Deficits more significant and long lasting • Adjustment issues are pronounced

31. Outside Resources: Neuropsychological Assessment: • Neuropsychological evaluation is a measure of brain-behavior relationships • Assessment of the following brain-behavior functions: arousal, attention and concentration memory, orientation, language visuospatial functions executive functioning psychological/ personality functions

32. School Based Treatment Team • School Psych • Social Worker • SLP • Classroom Teacher • Special Education Teacher • District TBI Liaison • OT • PT • Nurse • Administration • Student • Family • Paraeducator • Adaptive PE/Coach • AT Facilitator

33. Outside Resources: • Behavioral Optometry: Assesses how eyes work together and changes after an injury. • Counseling Services: Individual and family counseling to address adjustment issues. • Behavior Specialist: Address behavior management concerns.

34. Return to School after TBI: • Close Communication with Medical Team if possible (Medical Records request) • Have plan in place prior to student return to school if possible. • Careful assessment of student when they return in light of the cognitive, physical, emotional/behavioral changes. • Frequent re-assessment and communication among the school team to modify the program based on recovery or other changes in the student performance.

35. Return to School after TBI: • School staff who understand TBI and provide appropriate support are crucial to student success • Behavioral support is often a key piece of successful return to school • Don’t discount the impact of fatigue (physical and cognitive) • Headache and other physical issues can impact progress • Not all Students with TBI’s are the same

36. Programming for Return to School: Students with TBI May look like students with LD or ID but with important differences: • Students with TBI do not stay the same- need frequent re-assessment and program adjustment as they recover • Recovery can take weeks, months or years

37. Programming for Return to School: Differences between students with TBI and LD continued: • Students with TBI usually recall having normal abilities • Teaching may need to focus on compensatory strategies as well as re-teaching of specific skills • The goal is to meet the needs of the “whole person”