BrainSTEPS: Assists students, schools and families in Pennsylvania following acquired brain injury.

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





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




Non-traumatic Brain Injury

open head injury

closed head 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


Growing Up

Perf

orm

an

ce

Benefit of Intervention in Multiple Time Frames

Traumatic Brain Injury with Support


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

http://www.brainsteps.net/

http://www.pattan.net/



www.brainsteps.net

Available to orderIn bulk at:

www.pattan.net






www.brainsteps.net

Available to orderin bulk at:

www.pattan.net





BrainSTEPS: Assists students, schools and families in Pennsylvania following acquired brain injury.

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