brainsteps: assists students, schools and families in pennsylvania following acquired brain injury
TRANSCRIPT
BrainSTEPS: Assists students, schools and
families in Pennsylvania following acquired brain injury
The BrainSTEPS ProgramCreated by: PA Department of Health in 2007
Unique partnership for funding: PA Department of HealthPA Department of Education, Bureau of Special Education via the PaTTAN network
Implemented by: Brain Injury Association of Pennsylvania
Monica VaccaroProgram ManagerBrain Injury Association of Pennsylvania
Mary Lou BusbyBoard of Directors, Brain Injury Association of Pennsylvania
Brenda Eagan BrownBrainSTEPS Program CoordinatorBrain Injury Association of Pennsylvania
Program Steering Committee
What We Will Cover• Incidence and causes of brain injury
in children• Mechanisms of injury• Common Effects• Patterns of recovery• BrainSTEPS School Re-Entry Program• Concussion Management Team
Program
Traumatic Brain Injury STATISTICS
Brain injury is a leading cause of death and disability in children &
young adults.
Children with Traumatic Brain Injury 0-14 years of age
CDC StatisticsAverage ANNUAL number of Traumatic Brain Injury Emergency Department Visits and Hospitalizations in the United States
• Most children who sustained a TBI (91.5%) were treated and released from the emergency department.
United States. Centers for Disease Control. Traumatic Brain Injury in the United States. 2005. http://www.cdc.gov/ncipc/pub-res/TBI_in_US_04/TBI%20in%20the%20US_Jan_2006.pdf>.
509,000
Each year, approximately26,000
children in Pennsylvania sustain a traumatic brain injury
(mild, moderate, or severe)
Source: The Brain Injury Association of Pennsylvania, 2008
How Common is TBI in Children in Pennsylvania?
Mild:• Brief or no loss of consciousness• Shows signs of concussion
• vomiting• lethargy• dizziness• lack of recall of injury
Moderate:• Coma < 24 hours duration• Neurological signs of brain trauma
• Skull fractures with contusion (tissue damage)
• Hemorrhage (bleeding)• Focal Findings on EEG or CT scan
Severe:• Coma > 24 hours duration
Levels of Medical Severity of TBI
In 2006
approx. 4,000Children & Adolescents in
Pennsylvania were HOSPITALIZED with
TBI
Source: The Pennsylvania Department of Health, 2006DOES NOT INCLUDE EMERGENCY ROOM VISITS.
Focus:
Why the Discrepancy?
• Not all children who sustain a brain injury experience lasting effects
• Not all parents want to have their child classified – they want the child back to “normal”
• The effects of a brain injury can be latent.
• Effects of TBI may mimic other disabilities leading to misdiagnosis and inappropriate placement
• Under-identification and Misidentification within the educational system.
Acquired Brain Injuries :
Traumatic &
Non-Traumatic
Types of Brain Injury
Acquired Brain Injuryafter birth process
Traumatic Brain Injury
external physical force
Non-traumatic Brain Injury
open head injury
closed head injury
Definition of Acquired Brain InjuryAn injury to the brain that has occurred after birth. The injury commonly results in a change in neuronal activity, which effects the physical integrity, the metabolic activity, or the functional ability of the cell. An acquired brain injury may result in mild, moderate, or severe impairments in one or more areas, including:
• Cognition• Speech-language
communication• Memory• Attention/concentration• Reasoning• Abstract thinking• Physical functions• Psychosocial behavior• Information processing
Types of Brain Injury
Acquired Brain Injuryafter birth process
Traumatic Brain Injury
external physical force
Non-Traumatic Brain Injury
open head injury
closed head injury
Non-Traumatic Brain Injury Causes
Cerebral Vascular Accidents Vascular Occlusions Hemorrhaging Aneurysms
Ingestion of Toxic Substances Inhalation of Organic Solvents Ingestion of Heavy Metal Alcohol and Drug Abuse
Infections of the Brain
Hypoxia – reduced oxygen to the brain
Anoxia – no oxygen to the brain
Brain Abscesses Meningitis Encephalitis
Non-Traumatic Brain Injury Causes
Anoxia – common causes• Respiratory arrest• Electrical shock• Heart attack• Brain tumor• Heart arrhythmia• Extreme low blood pressure• CO2 inhalation• Poisoning• Choking• Suffocation• Respiratory conditions that affect breathing
Lightning
Near Drowning
Brain Tumors & Cancer Chemotherapy/Radiation Effects
Bleeding in the brain
Acquired Brain Injuryafter birth process
Traumatic Brain Injury
external physical force
Non-traumatic Brain Injury
open head injury
closed head injury
Types of Brain Injury
Definition of traumatic brain injury
or both, that adversely affects a person’s performance”
“an acquired injury to the brain caused by an external physical force, resulting in total or partial functional disability or psychosocial impairment,
Brain Injury Association of America
Open Head Injury: Gunshot Wound
Centre for Neuro Skills
What Happens During a
Closed Head Injury?
Skull Anatomy Dr. Mary Pepping of the University of Idaho’s presentation The Human Brain: Anatomy,Functions, and Injury
Bony Ridges
The skull is a rounded layer of bone designed to protect the brain from penetrating injuries.
The base of the skull is rough, with many bony protuberances.
These ridges can result in injury to the temporal and frontal lobes of the brain during rapid acceleration.
Skull Protrusions
Shaken Baby Syndrome
Car Accidents
EACH YEAR – Hundreds of Thousands of Student Athletes Sustain Concussions
Defined as a trauma-induced alteration in mental status (dazed, disoriented, confused)
May or may not involve loss of consciousness
Can result in loss of memory for events immediately before or after trauma
Can result in local neurological deficits that may or may not be transient
If concussion occurs as a sports or recreational injury
Clearing for return to play Challenges students faceTreatment & compensatory
strategiesFacilitating a successful
school re-entry
Signs and Symptoms of Concussion
Decreased Processing SpeedShort-Term Memory ImpairmentConcentration DeficitIrritability/DepressionFatigue/Sleep DisturbanceGeneral Feeling of “Fogginess”Academic Difficulties
Post-Concussion Syndrome(persistent symtoms)
A Child’s Brain
A Child’s Brain
• Underdeveloped – the younger the child, the less developed is their brain
• Easily Injured – infant’s neck is weak
• Unlike the heart or kidney, the brain needs time & experience to mature
• Undifferentiated – as learning occurs, specialization develops in the brain
A Child’s Brain
•New abilities build on ESTABLISHED skills over time
•Brain injury interrupts skill development, and can prevent new skills from developing
•Child’s brain was thought to have “plasticity,” yet does not “bounce back” after injury
Rates of Development:5 Peak Maturation Periods
Peak Maturation PeriodsFIVE distinct stages between the ages of 1
and 21 yrs.
% of maturation increments
age increments
1 3 5 7 9 11 13 15 17 19 21
6
4
2
0
Frontal lobes still developing
Brain Injury & Developmental Stages
• In the normal brain, cognitive, emotional, & social abilities emerged developmentally.
• Abilities developed at one stage of life form the foundation for more complex abilities later on.
Brain Injury & Developmental Stages
• Capacities in the process of development, and those not yet developed are those most vulnerable to brain injury.
• The earlier the injury, the more pervasive the impact on thinking, emotional regulation, and behavior.
Important Developmental Stages
• Child’s stage of development when injury happened
• Child’s stage of
development NOW
Growing Up
Perf
orm
ance
Normal Development
Development Without Brain Injury
Diagram by Dr. Sandra Chapman,University of Texas
Growing Up
Perf
orm
ance
Brain Injury
Normal Development
Traumatic Brain Injury Without Intervention
Diagram by Dr. Sandra Chapman,University of Texas
Growing Up
Perf
orm
an
ce
Benefit of Intervention in Multiple Time Frames
Traumatic Brain Injury with Support
Diagram by Dr. Sandra Chapman,University of Texas
Pre-Existing Conditions & TBI
• Children with pre-existing behavioral weaknesses are much more likely to have a TBI.
• Effects of TBI will compound and add to pre-existing learning, behavioral or psychological problems, such as:
»Dyslexia»ADHD»Paranoia»Depression
Visible, physical recovery is a sign that the brain is healed...
REALITY: Cognitive &
behavioral effects of a brain injury can last long after the
person heals “on the outside”
Younger kids are more resilient & can “bounce back” easier and more quickly after a brain injury...
REALITY: It may just take longer for the
effects of a brain injury to show up in a developing brain
M Y T H :
M Y T H :
Tennessee’s Project Brain, 2008
Effects of Brain Injuryon Children
Physical Effects
• Seizures • Headaches• Changes in speech & language• Sensory changes
TasteSmellHearingVision
Physical Effects
• Reduced Stamina
• Weakness- Navigating between classes
quickly - Carrying books - Physical Education class impact
• Difficulty with balance, paralysis, paresis, spasticity
Cognitive Effects
• Attention or concentration
• Ability to initiate, organize, or complete tasks
• Ability to sequence, generalize, or plan
• Flexibility of thinking, reasoning, or problem solving
Cognitive Effects
• Abstract thinking
• Information processing (slowed speed)
• Judgment or perception
• Long-term or short-term memory
Cognitive Effects
• Confabulation
• Ability to acquire or retain new information
• Inconsistent and unpredictable learning rate
Psychosocial Adjustment
• Family’s Ability to
Cope
• Denial of Illness
• Affective Problems
Psychosocial Adjustmentis Influenced by:
• Behavioral Problems• Cause of Behavior Problems
• Pre-Injury Personality Traits
Social, Emotional,Behavioral Issues• Distractibility
• Impulsivity• Irritability• Aggression• Motivation & Initiation• Depression• Lack of Social Judgment• Denial/Lack of Self-Awareness• Rigidity/Inflexibility• Low Frustration Tolerance
Brain Injury VS. Other Disabilities
Similarities Between Students with TBI & Students with Other
Neurologic Disabilities
Skill Integration
Generalization
Abstract Reasoning
Social Judgment
Problems with:
Attention
Memory
Impulse Control
Organization
What is Different AboutBrain Injury?
• Prior normal development
• Sudden onset of disability
• Require hospital to school transition planning
• Ongoing medical needs
• Cognitive, physical, and psychological impact
What is Different about Students with Brain Injury?
• TBI results in disruption of normal brain development
• Reconciliation of “old” self with “new” self
• Loss of peer relationships & change in family dynamics
What is Different About Students with Brain Injury?
• Exacerbation of prior difficulties
• Having to learn HOW to learn again
• More extreme discrepancies among abilities
• More uneven and unpredictable progress
What is Different About Students with Brain Injury?
Relearning of old material - may learn faster at first
Problems are not developmental
Reliance on previous learning strategies – might not be effective now
Psychological Testing
• TEST SCORES on typical school psychological & IQ tests are NOT indicative of future learning capabilities for a TBI student. Many tests measure only previously learned skills, which tend to remain intact after a brain injury.
• Usually perform fairly well during ONE-on-ONE testing that has no generalization or carry-over
• Evaluation MUST be ongoing.
BrainSTEPS: Assists students, schools and
families in Pennsylvania following acquired brain injury
BrainSTEPS Assists Students with All Acquired Brain Injuries
• Traumatic Brain Injury (includes Concussions)
• Non-Traumatic Brain Injury
* Any child who has a brain injury that occurs AFTER
the birth process can be referred to BrainSTEPS
The BrainSTEPS Program
• Brain injury consulting teams available to families and schools throughout Pennsylvania.
• Teams are extensively trained in the educational needs of students returning to school following brain injury.
• Teams consult with & train local school staff to develop educational programs.
• 31 BrainSTEPS teams cover PA• 29 are based out of the educational
Intermediate Units and 2 school districts
• 300+ active, trained BrainSTEPS team members– Educational professionals– Medical professionals– Rehabilitation professionals– Staff from community facilities – Staff from government agencies– University faculty– Family members
BrainSTEPS Teams
Hospital & Rehabilitation Team MembersChildren’s Hospital of Philadelphia The Children’s Institute of
Pittsburgh
Acadia Rehabilitation, Inc. Lehigh Valley HospitalGood Shepherd Rehabilitation Nemours/A.I. duPont Hospital
for Children (Delaware)
Beechwood NeuroRehab Mainline RehabilitationThe Barber Institute Magee Rehab HospitalGeisinger Medical Center Schuylkill RehabilitationReading Hospital St. Vincent’s Medical Center
What BrainSTEPS Teams Can Do:1.Prepare the student for return to school
2.Communicate with the district & medical, & rehab professionals
3.Gather medical, rehab, & educational reports/evaluations to assist in making educational recommendations
4.Conduct student observations
5. Provide peer, parent and school training5. Individual to student needs for school
teams6. General for district wide in-service
trainings
6. Consult on all aspects of the student’s educational plan & make recommendations to the district team
7. Assist in transitioning a student from grade to grade or school to school by training new teachers
What BrainSTEPS Teams Can Do:
What BrainSTEPS Teams Can Do:8. Serve as a consistent point of contact for
students
9. Offer families support, education and connections to community resources
10. Continually update their brain injury expertise by attending mandatory BrainSTEPS trainings, obtaining CBIS certification, and participate in other brain injury training opportunities
11. It is a goal of the BrainSTEPS Teams to monitor all referred students annually
until graduation.
• Communication with family• Communication with school• Consultation with student• Records review• Consultation: strategies• Consultation w/ medical professionals• Consultation educational plan• Training of educators and support staff• Classroom and peer education• Information sharing among team• Demonstration of interventions• Observations/evaluations of student• Participation in IEP and 504 meetings
BrainSTEPS Consultation Activities
Who is referred to BrainSTEPS?
A student who:1. Has an acquired brain injury
• At any point in the student’s life
2. Is having difficulty at school as a result of the acquired brain injury
• Concussions – referrals taken at 4wks. post unless there are “concussion modifiers” present
• All other brain injury severities – referrals taken at any point in time. The sooner the better
How to make a student referral to BrainSTEPS
BrainSTEPS referralswww.brainsteps.net
Students Served by BrainSTEPS:
Students 2,387
• Female: 45%• Male: 55%
Most prevalent AGE AT INJURY for referrals continues to be:14 yrs & 15 yrs
Students referrals from:65 out of 67 countiesand620 School Entities (public, private, charter)
Intermediate Units2%
Schools55%
Family20%
Hospital/Physician
13%
Rehabilitation facilities
7%
Other3%
Referral Sources
14%
86%
TraumaticNon-Traumatic
11%
89%Moderate & SevereMild (Con-cussion)
Injury Type and Severity
BrainSTEPS Concussion Support
2013 - Statewide Return to School
Concussion Management Team Project
Schools should ensure that cognitive demands (school work) placed on a
student are below the student’s individual symptom threshold
Return to School BrainSTEPS Concussion Management Team Project (CMT) 2013
– 2 CMT monitors• Academic Monitor (School Psych, Guidance Counselor)
• Symptom Monitor (School Nurse)
– 700+ CMTs formed & trained by BrainSTEPS
across the state of PA since January 2013 (as of 8/2013)
– CMTs follow BrainSTEPS Return to School Concussion Protocol
School Work After Concussion
Informal Accommodations/Adjustments100%
Formal ACCOMMODATIONS / BrainSTEPS Brain Injury Supports Framework / 504 Plan10-20%
MODIFYVery, veryfew
Initial 4
Weeks
Beyond 4
Weeks
Beyond6
months
Concussion
CMT MonitoringSchool level
BrainSTEPS Intervention @ 4 wks - IU level
PA’s Unique Layered Statewide Infrastructure for Concussion Return to School
1st
layer2nd
layer
Resources
Available fordownload at:
www.brainsteps.net
Available to orderIn bulk at:
www.pattan.net
Available fordownload at:
www.brainsteps.net
Available to orderIn bulk at:
www.pattan.net
Available fordownload at:
www.brainsteps.net
Available to orderin bulk at:
www.pattan.net
Available fordownload at:
www.brainsteps.net
Available to orderin bulk at:
www.pattan.net