RECOVERING BRAINS:

Understanding Traumatic Brain Injury and the Supports

Needed for Student Success

Kim Leaf M.A. CCC- SLP

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.

AGENDA

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.)

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

TYPES OF TBI’S2 type of Brain Injuries

1) Closed Head Injury- no break in the skull

2) Penetrating brain injury- a break in the skull

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

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

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

SEVERITY OF TBI Mild

Brief or no loss of consciousnessShow signs of concussion

ModerateComa <24 hoursNeurological signs of brain traumaFocal findings on EEG or CT Scan

SevereComa >24 hours

POST CONCUSSIVE SYNDROME (PSC)

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

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

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

COMPLICATIONS FROM TBIChanges in Skill Areas: Cognitive Physical Sensory/Perceptual Communication Social Emotional/Behavioral

Post Concussive Syndrome-PCS

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

PHYSICAL CONSEQUENCES Paralysis or weakness Spasticity Decreased balance, endurance Delays in initiation, tremors Swallowing problems Poor coordination Headaches Fatigue

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

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

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

REGULATORY CHANGES Fatigue Changes in sleep patterns, eating Dizziness Headaches Bowel and bladder problems Body temperature

PERSONALITY CHANGES Apathy Decreased motivation Emotional lability Irritability Anxiety and depression Disinhibition

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

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

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

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

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.

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

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.

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

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

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

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.

RETURN TO SCHOOL AFTER TBI:1. Close Communication with Medical Team

if possible (Medical Records request)2. Have plan in place prior to student

return to school if possible.3. Careful assessment of student when

they return in light of the cognitive, physical, emotional/behavioral changes.

4. Frequent re-assessment and communication among the school team to modify the program based on recovery or other changes in the student performance.

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

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

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”