Understanding and Helping Students with Brain Injury

Julie Dawning, MSP, CBISPediatric Resource Manager

Washington TBI Resource Center 11/3/2014

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Brain Injury statistics and termsHow to screen for Brain InjuryAll about concussionsWhat does cognitive and physical rest mean?How Brain Injury may impact learningHow to support return to school/playAbout the Brain Injury Alliance of Washington

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Today you will learn:

Before we get started…

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How many people in the room have provided services to an individual with Brain Injury? …with a concussion?

In Comparison…

Information from “The Essential Brain Injury Guide” BIAA, 20094

Brain Injury in the U.S.TBI is the THIRD most prevalent disability among Americans

TBI is the leading cause of both death and disability in children and youth in the US.

In every age group, males have higher rates of TBI than females.

Individuals who experience 1 TBI have an increased risk for re-injury.

47% of high school football players have suffered a concussion*

35% have experienced at least two*

20% of athletes fake being symptom free*

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Information from “The Essential Brain Injury Guide” BIAA, 2009*Statistics quoted from Seattle Times article November 4, 2008

Misidentifications• Depression• Learning Disabled• Drunk• Anxiety Disorder• PTSD• Schizophrenia

• Brain injury is often called an invisible injury. • People with Brain Injury may seem fully recovered,

especially if they have no physical disabilities. • Cognitive, emotional, and behavioral problems may linger

and appear when the person is stressed. 6

Misconceptions

• All Brain Injury can be prevented• A more complete or swifter recovery can be

made• The brain heals at the same rate as the body

after an accident

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• A person with Brain Injury is “lazy”

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Screening for TBI

• Increased awareness of TBI leads to better outcomes.

H = Hit in the head

E = Emergency room treatment

L = Loss of consciousness

P = Problems with concentration

and memory

S = Sickness or other physical

problems following injury If you have a student who fits two or more of the above, professional assessment is recommended.

International Center for the Disabled, HELPS Screening Tool, 1992

Brain Injury Terminology

• Brain Injury = Damage to the brain that causes the death of brain cells and/or impaired brain functioning.

• Acquired Brain Injury (ABI) = Damage to the brain caused by events after birth such as stroke, anoxia, brain hemorrhage, tumor, and other degenerative diseases of the brain. (May include TBI.)

• Traumatic Brain Injury (TBI) = Damage to brain tissue caused by an external force. ---a blow/hit to the head resulting in death of brain cells or changes in brain functioning.

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Brain Injury Terminology

• Closed Head Injury = A brain injury in which the skull and outer protective brain membrane (dura mater) remain intact.

• Open Head Injury = An injury to the brain in which the outer protective brain membrane (dura mater) is broken through.

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Brain Injury Terminology

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• Contusion• Hematoma• Anoxia• Skull Fracture• Coup contra Coup• Diffuse Axonal Injury• Post-traumatic seizure• Concussion

A Concussion is a Brain Injury!

Concussion

• A concussion is the most common type of Brain Injury

• It is caused by movement of the brain inside the skull within the cerebral fluid.

True or False:• A concussion can be

identified most easily by loss of consciousness (LOC)

• A concussion is diagnosed by a brain scan.

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Concussion Facts

• True or False:

It takes a week or longer to recover from a concussion.

Before a concussion has healed, even a small subsequent hit to the head may cause death or permanent disability. 13

Complications

• The effects of concussion are usually temporary, but if unidentified and not treated appropriately, they may linger or cause permanent damage.

• The duration of symptoms is more significant than the seriousness of symptoms…Post Concussive Syndrome.

• Second Impact Syndrome: Before a concussion heals, even a minor impact may result in a catastrophic brain injury or death (in a small percentage of cases).

• Playing with a concussion can be deadly!

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Possible symptoms of concussion

Signs observed by others:• Hit or jolt to the head• Temporary loss of consciousness • Appears dazed or stunned• Confused, disoriented• Difficulty remembering/concentrating• Vomiting• Behavior or personality changes• Muscular weakness, poor coordination, paralysis• Slow response time • Slurred speech

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Possible symptoms of concussion

Symptoms reported by athlete:• Headache, pressure in head • Nausea • Dizziness or balance problems• Double or blurry vision• Sensitivity to light and/or sound, • Ringing in the ears• Feeling sluggish• Feeling foggy or groggy• Concentration or memory problems• Confusion

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Emergency attention needed if any of the following signs are present:

• Loss of consciousness greater than 30 seconds• Seizures• Too drowsy to awaken• Repeated vomiting• Slurred speech• Can’t recognize people or places• Weakness or numbness in arms or legs• Neck pain• Unusual behavior change• Increasing confusion and irritability• Headaches that get worse

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What to do if you suspect concussion…

• Always remove the athlete from play.• Inform the athlete’s family and teachers.• Make sure the athlete is evaluated by an

appropriate health care professional. • If the family’s PCP is not familiar with concussion,

refer them to:Heads Up: Brain Injury in Your Practicehttp://www.cdc.gov/concussion/HeadsUp/physicians_tool_kit.html

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The Zackary Lystedt Law

• The Lystedt Law requires an athlete with signs of a concussion to receive written clearance from a licensed healthcare professional trained in the evaluation and management of concussion before returning to play.

• Provision of a wallet sized list of concussion symptoms to families and coaches is recommended.

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Cognitive and Physical Rest

• The brain requires more energy than usual to heal.• The brain is less efficient in parsing out energy to the

areas that are being used.• Energy previously devoted to cognitive tasks may be

now used for screening senses and planning motor tasks.

• Therefore, a healing brain tires more easily.• Follow doctor’s orders closely.• The extent of rest required can be monitored

by noting symptoms such as fatigue and headaches.

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Return to play/school…

Notify the athlete’s teachers of the known or possible concussion.• Make sure that absences and activity/study restrictions are

formally recognized to support healing while maximizing education.

• The goal of education is the learning that results from various tasks, not the tasks themselves.

• Find other ways to teach main points and to have the student demonstrate learning.

• A graduated return to play and school should be followed.

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Return to play/school…

• Develop a working relationship as a team.– Family and student, friends, interpreter, daycare provider,

parent coach– Hospital educators, rehabilitation providers and

neuropsychologists– Medical doctors, mental health counselors, BIAWA resource

managers

• Interventions are most successful when shared across environments.

• Home/Hospital Instruction or at home tutoring may be necessary for convalescence.

• A 504 Plan is a great tool for immediate school access.• Remember that the student is healing, so their condition will

change. 22

REAP----Coming Soon

How might brain injuries impact learning?

• Sensory Changes• Motor Skills• Memory• Organizational Problems• Transitions• Mental Processing• Executive Processes• Social Emotional Symptoms• Speech and Language Symptoms

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From the Center on Brain Injury Research and Training “Traumatic Brain Injury, an Overview” http://www.cbirt.org/resources/interactive-learning-modules/module-tbi-an-overview/

Neuropsychological Evaluation

• Neuropsychological tests are designed to examine a variety of cognitive abilities, including speed of information processing, attention, memory, language, and executive functions, which are necessary for goal-directed behavior.

• Neuropsychologists can make inferences about underlying brain function.

• Neuropsychological tests include detailed individualized recommendations for the education program as well as social, emotional and behavioral supports.

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Energy PieNormal & After a Mild Brain Injury

27Adopted from “Brain Injury Survival Kit” by Cheryle Sullivan, MD. Chart copyright of Mary Lou Acimovic, MA

Sensory Changes…

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Memory…

• Difficulty learning new information• Difficulty retrieving information• Difficulty juggling multiple tasks• Difficulty following multi- step processes• Challenges applying

learning to new situations29

Mental Processing

• Decreased processing speed • Abilities and skills may be uneven---

– Across settings– Over time– In different context areas

• Students may appear “unmotivated” or or “not working up to potential”

• Impacts to executive functions– Initiation– Attention– Flexibility

• Difficulty with transitions

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Social Emotional Symptoms…

• Emotional lability • Disinhibition• Irritability, frustration• Depression, anxiety• Aggression • Lack of self awareness• Changes in social relationships

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Speech and Language Symptoms…

• Difficulty speaking or understanding the spoken word

• Difficulty understanding inferences, double-meanings, humor, social cues

• Problems reading and writing• Difficulty with comprehension

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Social Nuances• Makes others uncomfortable

– Does not recognize social boundaries– Unable to read body language, tone of voice– Inappropriate comments, responses

• Poor hygiene• Apparently strange eating behaviors• Lack of awareness of dysfunction

(Anosygnosia)

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Self Advocacy Limitations

• Remembering what to ask• Remembering what was learned• Remembering what to do next

• Deciding when one needs help• Attending school reliably• Making and remembering safety

plans• Accurately assessing danger• Defending oneself from physical or

sexual assault • Finding other needed services

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What techniques might help individuals with Brain Injury?

• Remember: each brain injury is unique.– The diversity of effects of Brain Injury stems from the fact

that the brain controls all aspects of biological functioning. • Individuals may have widely

varying skills--- “splinter skills” • What works for one individual may not

work for another.• What works today may not work

tomorrow, or next week.

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General guidelines…

• Include the individual as much as possible in educational planning

• Design a plan that is simple, clear and achievable– Errorless Learning is recommended for individuals with

diminished cognitive capacities– http://

www.projectlearnet.org/tutorials/errorless_learning.html– Collaborative Problem Solving can also help – http://www.ccps.info/

• Be consistent across environments,

reinforcing learning• Be flexible when circumstances change

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General guidelines…

• Practice, repeat, practice, repeat• Prepare individuals so that they can be successful—

create predictability• Keep your comments about the individual positive---

share their successes with others in front of them

• Stay calm; avoid arguments;

keep your sense of humor• Don’t take things personally• Be patient, give the student time to

collect their thoughts• Use visuals and hands on

approaches as needed

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Strategies to Empower

• Speak clearly and concisely• Minimize distractions• Create a quiet location• Minimize bright lights

• Limit the length of work • Build in short breaks—perhaps with

movement

Attention and Concentration

Strategies to Empower• Support concentration

– Keep voice and facial expression congruent– Talk slowly and stay on point– Focus on one thing at a time– Allow time for responses – Provide outlines– Allow use of manipulatives option to stand, move around– Provide warnings for transitions

• Capitalize on learning styles– Brain Injury can impact ability to process verbal, visual,

spatial, motor information 39

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Strategies to Empower

• Ask yes-or-no questions.• Provide written as well as verbal information.• Introduce new material in the context of familiar

material.• Have the student repeat new information; use

mnemonics, visualization, etc.• Break tasks down into steps---write down and

check off as completed.• Use daily planner, to-do lists, cue cards, alarm

cues.

Information, Processing and Memory

Strategies to Empower• Assist memory

– Be factual, not abstract– Ask yes-or-no questions– Provide options– Provide support BEFORE a mistake is made when

teaching new information—errorless learning– Lots of practice, repeat, repeat, repeat– Set alarms

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Provide reassurance and structure to help decrease anxiety…Encourage as much self-determination as possible!

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Strategies to Empower

• Help prioritize goals.• Help create ways to track the process. • Write out general steps to planning or

problem-solving tasks. • Identify possible short and long-term

consequences of specific choices.• Provide clear and specific feedback.

Executive Functioning

Problem Solving GuideState Problem:_________________________List 3 solutions: 1)_____________________ 2)_____________________ 3)_____________________

Solution 1 Solution 2 Solution 3 Pros Cons Pros Cons Pros Cons

Describe the most logical and effective solution based on the above:________________________________ _____________________________________

Remember, those with frontal lobe damage may have difficulty establishing goals, taking action to achieve goals, inhibiting behaviors that prevent achievement of goals.

*Adapted from the Rhode Island BIA presentation “Brain Injury: A Practical Training for Caregivers”

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Strategies to Empower

• Executive Functioning– Break tasks up into small, tangible,

sequential steps– Allow extra time to complete tasks– Track process with frequent follow up– Help fill out forms and make important

phone calls

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Strategies to Empower

• Developmental Milestones may pose challenges for individuals with Brain Injuries.

– Abilities that are just developing are very vulnerable at the time of Brain Injury.

– Developmental Milestones coming after Brain Injury may be less easily negotiated, as higher level processing/thinking is required.

Healthy Development

Strategies to EmpowerPositive Behaviors

Most people with Brain Injury are not inherently aggressive or assaultive; however, when challenges are not properly addressed it can lead to:• Lack of proper responsiveness/ task refusal• Property destruction• Verbal or physical aggression• Violation of personal or sexual boundaries• Wandering or flight• Self harm/self abuse/suicide

Others’ not recognizing the basic challenges to an individual with TBI is often cited as a cause of this.

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Strategies to EmpowerPositive Behaviors

– Develop trusting relationships• honest, caring, and consistent interactions• comfortable, nonjudgmental atmosphere • feedback and support from social network

– Understand behavior• Identify triggers, antecedents

– fatigue, hunger, lowered self-esteem– frustrating task, interaction with certain individuals, change in routine, increased level of stimulation

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Strategies to EmpowerPositive Behaviors

• Identify warning signs– Pacing, fidgeting, getting red, decreased attention, muttering, raised voice

• Identify reinforcing consequences (what happens after the behavior)

– Positive reinforcement: attention, praise – Negative reinforcement: removal of undesired task,

avoidance, attention– Ask them, their family and friends– Note what makes them smile

– Create a planWe CANNOT control the behavior of others. We CAN control our behavior and adjust the environment.

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Strategies to EmpowerPositive Behaviors

– Create a plan with the individual• Collect data for baseline• Consider their strengths and

weaknesses–Use strengths, accommodate for

weaknesses• Utilize their learning style, or multiple

styles• Base new learning on pre-existing

learning

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Strategies to EmpowerPositive Behaviors

• Change the environment– Positive consequences: rewards, privileges,

incentives, attention, praise » Identify motivators: ask, note what

makes them smile– Negative consequences: removing

privileges---not as effective as positive consequences

– Reinforce desired and incompatible behaviors

– Alternate preferred and non-preferred activities

– Teach in the moment in order to help with generalization

– Go for improvement– Fade out intervention

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Positive Self Image• Individuals with Brain Injuries often

remember how they functioned before the injury and are able to compare current functioning to past functioning.

• Reinforce their dignity as a unique human being regardless of accomplishment level.

• Help them find something they enjoy and are good at:– Consider non-dominant brain functions such

as art and music

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The Brain Injury Alliance of Washington (BIAWA) Services

The Washington TBI Resource Center : • Statewide Toll-Free Resource Line, M-F 9:00-5:00

1-877-824-1766• Resource Management• Clinical Case Management

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Where is In-Person Resource Management?

* Resource Management is available over-the-phone throughout the entire state of Washington.

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What do Resource Managers Do?

• Provide basic Brain Injury information• Help the individual/family identify goal(s) and action steps to achieve

goal(s)• Connect individuals to Support Groups, Social Activities/Events, and

other Support Services • Collect records• Coordinate Health Care• Apply for Government Assistance• Identify financial aid, low cost programs, and transportation options• Find appropriate/stable housing • Coordinate services across environments/systems • Help individuals/families to self advocate

Outreach/Training: BIAWA is available to provide free, customized training on Brain Injury to educators, medical providers, legal professionals and other service providers. Social Outings: BIAWA recognizes the valuable role of social engagement in enriching the quality of life for individuals with Brain Injury and their families. Activities Include: Strolling Through the Tulips, Baseball with BIAWA, Pizza Parties, Dinner at Pyramid, and scholarships to the Annual Gala and other BIAWA ticketed events. Support Groups (60)Washington’s Brain Injury Support Groups strengthen communities through peer support. You can get more information about these groups on our website or by calling the Washington TBI Resource Center at 877-824-1766.

BIAWA Supports Washington Through

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For More Information

Julie Dawning, MSP, CBISAdult and Pediatric Resource Manager

julied@biawa.org

TBI Resource Center1-877-824-1766

www.biawa.orgwww.facebook.com/braininjurywa

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Thank You!