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
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.
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.
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.
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!
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.
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.
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.
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.
Agree
Neutral
Disagree
Don't know
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
Tag… YOU’RE IT!
Goals
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Understanding Traumatic Brain Injury
Identification and Assessment
Advocacy and Your Role
Resources
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.
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.
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.
Types of Brain Injury
B ra in In ju ry
C o ng e n ita l an d P e rina tal
A c qu ired
(n o pe riod o f n o rm a l de v elo p m e n t)
(follow ing a period of norm al dev elopm ent)
P e rina tal
C o ng e nital
N o n -trau m a tic
T ra um a tic
(e .g ., b irth s trok e)
(e .g ., P K U )
(in te rna l occurren ce
e .g., tu m o r)
(e xte rna l p hysica l fo rce)
O pen
C losed
(e.g., gunshot)
(e .g ., fa ll)
Examples
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Traumatic Brain Injury
Stroke
Brain Tumor
Seizure Disorder
Anoxic event
Infectious disease such as Encephalitis
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.
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.
Parts of the Brain
Parts of the Brain
Severity of Brain Injury
• Mild
• Moderate
• Severe
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
Concussion: Sports related
injuries
Immediate Presentation:
Delayed effects:
Mild Traumatic Brain Injury:
Typical Early Recovery
• Common effects
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Headaches
Lethargy
Dizziness
Sensory
hypersensitivities
– Poor concentration
• Course
– About 80%
uncomplicated mild
TBI’s fully recovery by
3 months
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
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
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
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)
Severe Traumatic Brain Injury:
Definition
• Coma more than 24 hours
• Post Traumatic Amnesia more than 1 day
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
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
Typical Medical Course for a Student
with a Moderate/Severe TBI
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Emergency room
Regional trauma center if necessary
Surgery if necessary
Acute care setting (hospital)
Rehabilitation unit or center
School
Which student has a TBI?
• Can you tell?
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
Physical/Medical Problems
• Problems
– Seizures
– Fatigue
– Headaches
– Swallowing/Eating
– Self-care activities
• Medication issues
Most Common Physical Deficits:
• Physical Endurance
• Mental Endurance
• Headaches
Motor Problems
• Apraxia
• Ataxia
• Coordination
problems
• Paresis or paralysis
• Orthopedic problems
• Spasticity
• Balance problems
• Impaired speed of
movement
Most Common Motor Problems:
• Balance
• Fine Motor Dexterity
• Motor Speed
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
Most Common Sensory/
Perceptual Issues:
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OVERSTIMULATION!
Double Vision
Neglect / Inattention
Hypersensitivities
Cognitive-Communication
Problems
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Executive functions
Memory
Attention
Concentration
Information
processing
• Sequencing
• Problem solving
• Comprehension of
abstract language
• Word retrieval
• Expressive language
organization
• Pragmatics
Most Common CognitiveCommunication Deficits:
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Slowed Processing Speed
Intolerance of Complexity
Attention
Memory
Emotional & Behavioral Problems
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Irritability
Impulsivity
Disinhibition
Perseveration
Emotional Lability
Insensitivity to social
cues
• Low frustration
tolerance
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Anxiety
Withdrawal
Egocentricity
Denial of deficit/lack
of insight
Depression
Peer conflict
Sexuality concerns
High risk behavior
Most Common EmotionalBehavioral Problems:
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Fragile Emotional Control
Poor Awareness
Impulsivity
“Just don’t get it”
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
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
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
TBI: How is it Different?
TBI
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 Not based on
learning disability impaired cognition
Difficulties
with
Learning
Old info easier to recall than New learning
new info
can be linked
with old learning
New learning
can be linked
with old learning
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
Challenges to Evaluation: Student
Factors
• Rapidly changing skills (especially during first 612 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
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
How can I gather more info?
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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
Intervention
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Environment (space and time)
Instruction and materials
School staff
Peers
Student
Family
Pharmacological
Most Common Physical Deficits:
• Physical Endurance
• Mental Endurance
• Headaches
Endurance:
Middle
School
Primary
-Whining
-Low frustration tolerance
-Conflict with peers
High
School
-Shuts down at certain times of the
day
-More likely argumentative
-Slows down
-The slow blink
Mental Endurance
Environment
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
Headaches
Middle
School
Primary
-Vague complaints
High
School
-Most often able to be more specific,
but may under or overgeneralize
effect
-Increase with mental/physical
exertion
Headaches
Environment
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
Student
Educate other staff and peers; Encourage low stimulation
by other students
Family
Alert family; Keep journal and data
Medical
Explore medications, consult with family or rehab doctor;
side effects of current medications; screen vision
Encourage student to speak up at first sign of headache
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.
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
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
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
!!!
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
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
How can you Prevent?
• Educate
• Your participation with other programs
– Drug and alcohol abuse
– Drivers education
– Helmets and Safety
– Sports and concussions
– Violence prevention
Resources…at your fingertips
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www.braininjury101.org
www.tbied.org
www.projectlearnet.org
www.brainline.org
www.neuroskills.com
www.northeastcenter.com
www.tndisability.org
free.braininjurypartners.com
www.cdc.gov/concussion/HeadsUp/schools.html
Brain Injury Navigator
www.binav.org is a South Carolina
website aimed at providing up to date
information and resources to
educators, families and students
regarding brain injury and school reentry.
The BI Navigator will allow interested
parties to more conveniently and
directly access support materials.
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.
In addition…
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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
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
Talk about brain injury
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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