School Re-Entry after Traumatic Brain Injury

1. School Re-Entry after Traumatic Brain Injury Roger C. Peace Rehabilitation Hospital Anne Bradley, Ph.D Sarah Powell, M.Ed. CCC-SLP Please click on sound for instructions

2. Learning Objectives • Understanding TBI • Brain Recovery and Development • Returning to School • Identification and Assessment • Intervention and Classroom Accommodations • Advocacy and Resources

3. Preview of Section 1: Understanding Brain Injury • Appreciate the under-reported nature of TBI • Learn what a brain injury is • Learn how to identify the level of severity of a brain injury • Be able to generally predict the early course after injury.

4. 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.

5. 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.

6. Definition of TBI • Acquired Brain Injury • Congenital and Perinatal Brain Injury • Traumatic Brain Injury • Open Head Injury • Closed Head Injury

7. Acquired Brain Injury • Brain Injury incurred after a period of normal development • Internal causes • External causes

8. Congenital and Perinatal Brain Injury • No period of normal development • Congenital- a condition a child is born with such as a chromosomal abnormality • Perinatal- a condition that develops around the time of birth such as a perinatal stroke

9. Traumatic Brain Injury • 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 child’s educational performance.

10. Effects of Brain Injury • Injury to brain tissues at the site of damage • Shearing and tearing of neurons throughout the brain • Bleeding, swelling, and lack of oxygen to the brain • Possible coma

11. Severity of Brain Injury • Mild • Moderate • Severe

12. 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

13. Concussion: Sports related injuries Immediate Presentation: Delayed effects:

14. Mild Traumatic Brain Injury:Typical Early Recovery • Common effects • Headaches • Lethargy • Dizziness • Sensory hypersensitivities • Poor concentration • Course • About 80% uncomplicated mild TBI’s fully recovery by 3 months

15. 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

16. 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

17. 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

18. 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)

19. Severe Traumatic Brain Injury:Definition Coma more than 24 hours Post Traumatic Amnesia more than 1 day

20. 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

21. Severe Traumatic Brain Injury: Treatment • Short to very long stays in ICU/PICU/ NeuroICU’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

22. Review of Section 1: Understanding Brain Injury • Appreciate the under-reported nature of TBI • Learn what a brain injury is • Learn how to identify the level of severity of a brain injury • Be able to generally predict the early course after injury.

23. Preview of Section 2:Recovery and Development • Understand what is meant by “plasticity” • Understand the role of neural networks • Understand how plasticity contributes to brain development • Understand how plasticity contributes to recovery from brain injury • Be able to identify the limitations on plasticity • Be able to generally predict long-term outcome after brain injury

24. What is Brain Plasticity?

25. The Brain

26. Neural Networks: Neurons that Play Together, Stay Together

27. The Interconnected Brain: Axonal Tracts

28. For example: Corticospinal Tract

29. What is Brain Plasticity:

30. Brain Plasticity During Development 2 weeks old 1 year old 2 years old Adult Brain 2 weeks old 1 year old Adult Brain

31. Brain Plasticity During Development: Productive Events Neuron proliferation Prenatal Proliferative zone Across lifespan dentate region of the hippocampus

32. Brain Plasticity During Development: Productive Events Myelination Front to back progression Spike in production in temporal parietal lobes between 6 and 12 years old Growth drops off after 12 yo Adult brain

33. Brain Plasticity During Development: Subtractive Events Synaptic Pruning Those neural networks that are most frequently used are preserved Those that are used left often are destroyed

34. Brain Plasticity During Development: Gray Matter UCLA – Laboratory of Neuroimaging Brain mapping of subjects 3 through 20 years of age Time lapse of 2 weeks to 4 years Found both rapid growth as well as loss of gray matter

35. Brain Plasticity During Development: Gray Matter UCLA – Laboratory of Neuroimaging Proliferation in first 18 months and at puberty Generally a back to front progression of pruning across childhood and adolescence Extreme poles front to back mature first, then association areas during middle childhood, then frontal lobes during adolescence From 5 to 20 years of age warm = more volume cool = less volume

36. What is Brain Plasticity?

37. What Does Brain Injury Do?

38. What Does Brain Injury Do: Disruption of Neural Networks DTI of someone with Multiple Sclerosis

39. What is Brain Plasticity?

40. Plasticity after Brain Injury:Synaptogenesis

41. Plasticity after Brain Injury:Reorganization

42. Brain Development after Pediatric Brain Injury 2 weeks old 1 year old 2 years old 2 weeks old 1 year old Adult Brain

43. Brain Development after Pediatric Brain Injury Cost to Future Plasticity

44. Brain Development after Pediatric Brain Injury

45. Pediatric Brain Injury:Injury+Plasticity+Development=Outcome Cognitive Reserve Capacity Brain Reserve Capacity How long since injury? Where in development? What parts were affected? PLASTICITY OUTCOME

46. Pediatric Brain Injury:Injury+Plasticity+Development=Outcome Cognitive Reserve Capacity Brain Reserve Capacity How long since injury? Where in development? What parts were affected? PLASTICITY OUTCOME

47. Pediatric Brain Injury:Injury+Plasticity+Development=Outcome Cognitive Reserve Capacity Brain Reserve Capacity How long since injury? Where in development? What parts were affected? PLASTICITY OUTCOME

48. Pediatric Brain Injury:Injury+Plasticity+Development=Outcome Cognitive Reserve Capacity Brain Reserve Capacity How long since injury? Where in development? What parts were affected? PLASTICITY OUTCOME

49. Pediatric Brain Injury:Injury+Plasticity+Development=Outcome Cognitive Reserve Capacity Brain Reserve Capacity How long since injury? Where in development?

50. Pediatric Brain Injury:Injury+Plasticity+Development=Outcome Cognitive Reserve Capacity Brain Reserve Capacity How long since injury? Where in development? What parts were affected?