concussions in pennsylvania - amazon s3€¦ · classwork, homework, tests, assignments, behaviors...

1

www.brainsteps.net www.brainsteps.net

Return to Learn

Fall 2014 Webinar Series: Students (K-12) with Concussion

Educational Impacts, Return to School

Progression, & Symptom Based Accommodations

Brenda Eagan Brown, M.Ed., CBIS October 1, 2014


Brenda Eagan Brown, MEd, CBIS

BrainSTEPS Program Coordinator The BrainSTEPS Program

[email protected]


The webinars in this concussion series were created to

build the capacity of teachers working with students

who return to the classroom following concussion.

This series does not replace the official

PA BrainSTEPS Return to Learn (RTL) Concussion Management Team (CMT) Training.

Attendance during this webinar does not denote CMT formation or BrainSTEPS Team Membership.

This webinar is for educational purposes only.

If your Pennsylvania school district is interested in

forming a Concussion Management Team for

academic & symptom management, please register your CMT at www.brainsteps.net and online training

information will be sent to you.


If you have questions during the

webinar, feel free to email them to me at: [email protected]

We are not taking questions during the

webinar

This webinar is being recorded and will

be available online in one month at www.pattan.net and also at

www.brainsteps.net


Safe Kids Worldwide

1 child every 3 minutes

sustained a concussion

47% of these

concussions were in

children ages 12 -15 U.S. Consumer Product Safety Commission’s

National Electronic Injury Surveillance

System (NEISS) - 2013


Concussions in Pennsylvania:

Annually, approx. 22,000

children & adolescents sustain

concussions.

http://www.brainsteps.net/

mailto:[email protected]

http://www.pattan.net/


2

www.brainsteps.net

Following a CONCUSSION, there are

actual METABOLIC CHEMICAL

CHANGES that take place in the brain.

www.brainsteps.net

Brain injury can occur

even if there is NO loss

of consciousness

www.brainsteps.net

More than 90% of concussions

DO NOT involve loss of consciousness.

www.brainsteps.net

Memories of events BEFORE & AFTER the concussion are MORE accurate assessments

of SEVERITY than

loss of consciousness.

www.brainsteps.net

The majority of students should recover within the first 3-4 weeks,

many in the first

7-10 days.

www.brainsteps.net

A child’s brain is not fully developed until the early

to mid-20s.

3

www.brainsteps.net

Signs and Symptoms of Concussion

CDC, 2014


Prolonged Concussion:

Indicators that student’s concussion will most

likely take 1 month or more recover? (UPMC in Pittsburgh, 2012)

1. Fogginess

2. Vomiting

3. Dizziness

www.brainsteps.net


What teachers may observe:

• Multi-tasking difficulty

• More forgetful

• Slowed thinking & processing

• Answers questions slowly

• Word-finding problems

• Difficulty handling new situations



• Behavior changes

• Confusion

• More emotional than usual

• More frustrated than normal

• Unable to cope with stress



• Drifting off in class

• Difficulty focusing on material,

especially more difficult material

• Cannot keep focused for a sustained

period

• Restlessness

• Reports of “foggy” feeling

4

www.brainsteps.net

Physical & Cognitive

REST is crucial ACUTELY.


Keep in mind 2 Phases of Recovery:

1. The ACUTE Phase

2. The REHAB Phase

www.brainsteps.net

Too little rest: = prolonged recovery

Too much rest: = physical deconditioning

= social isolation


School Re-Entry

Progression


Return to Learn (RTL) While it is true that an athlete must be 100% symptom-free before Return to Play, they

do NOT need to be 100% symptom-free to

RTL.

www.brainsteps.net

Students Should Not Push Through Symptoms While Recovering

• exacerbates symptoms

• prolongs recovery time

Majerske, C., et al. 2008

5

www.brainsteps.net

Need for Rest After Concussion:

High levels of cognitive activity

= Longer recovery from concussion

(Brown et al., , 2014)

www.brainsteps.net

School Concussion Management

1. Return to Learn

2. Return to PLAY


Halstead, M.E., McAvoy, K., Devore, C.D., Carl, R., Lee, M., Logan, K. Returning to

learning following a concussion. Pediatrics 2013;132(5):948-957.

When Students Should Return to Sports


Acutely- Upon Return to School – Across the Board (length of time needed varies)

1. No note taking

2. Reduce all in class work to 50%

3. No tests, quizzes, standardized tests, or homework

4. Scheduled rest breaks

5. Excuse from all classes/activities that may be over- stimulating (light/noise)

6. Excuse from PE, recess, all physical activity


A word about Medical Homebound &

Homebound Instruction

• Keeping a student out of school for too long

can be harmful

– Socially, Emotionally, Academically

• Something is usually missing: – return to school plan

– academic accommodations

– staff wasn’t trained to understand concussion

– fluid, consistent communication between home/school/medical


New Learning

Missed Work

ONE or the OTHER rule

6


For students enrolled in a Career and

Technical Center (CTC)

Return to Tech vs Return to School

A Career and Technical Education (CTE) provides unique environmental and academic challenges for the concussed

student

Need to Be Separate Decisions


Educational

Accommodations


Academic Accommodation Decisions

Educational accommodation selection is the

responsibility of the School Team.

Medical academic accommodation suggestions are only RECOMMENDATIONS that the school team should take into consideration.

The school team needs to make the final decision for accommodation implementation based on collected academic data, symptom data, etc.

www.brainsteps.net

Helping the concussed student

remain in school while recovering.


For students who linger, striking a balance

between the need for rest and keeping up with academic content

is the biggest struggle.


Cognitive fatigue and headaches

• 50% of workload is commonly recommended

during recovery

• Assignments (homework/classwork) should not be repetitious.

7


Cued Recall is better than Random

Retrieval. Alleviate brain fatigue by using:



• Rest Breaks

• Removal from Cafeteria ?



• Chunking Assignments

• Water bottle

• Extra time

• Timelines to plan


Cognitive Fatigue & headaches

• Timeline for work - fatigue

• Don’t just say “Do what you can”


Testing • Acutely tests and quizzes should be delayed

(especially standardized tests)

• Gradually re-introduce testing, preferably 1

test/quiz per day, as tolerated

• Testing in a separate, quiet room

Cognitive fatigue & headaches


Sensitivity to Light & Noise

• Sunglasses, hat

• Face student away from bright lights

• Remove from over-stimulating classes

• Early dismissal

• Headphones or ear buds

www.brainsteps.net

8


Dizziness

• Allow extra time to get to class

avoid crowded hallways

• Walk with a peer/peer carry books

• Elevator key instead of stairs


Social/Emotional Early on-

Later on–


Social/Emotional

Develop an emotional support plan

with the student

• Identify an adult

• Identify a student


Educational Frameworks to

Safeguard

Persistent/Prolonged/Protracted

Concussions


Prolonged Concussion Recovery

• PCS

• Students should work to his/her symptom

threshold = REST, RECOVER, RETURN to Activity


Prolonged Concussion Recovery

• Physical Therapy

• Speech Therapy (cognitive rehab)

• Vestibular Therapy

• Vision Therapy

• Medications

• Counseling

9


Academic Supports After Concussion

Informal Supports 100%

Formal Supports 10-20%

INTENSIVE Very, very

few

www.brainsteps.net

If a student experiences lasting

effects that impact learning (school evaluation must first take place):

Concussion 504 Plan IEP


Not Special Education –

504 Plan/504 Service

Agreement


Who is Eligible for a 504?

504 Regulation 34 C.F.R. 104.3(j-l):

“a person with a disability as any person who has a physical or mental impairment that substantially limits one or more major

life activities*, has a record of such impairment, or is regarded as having such impairment.”

www.brainsteps.net

Section 504 of the Rehabilitation Act:

o The physical or mental impairment must impact at least 1 of 13 listed major life activities (Dr. Perry Zirkel, 2010):

1. Seeing 8. Concentrating

2. Hearing 9. Sleeping

3. Walking 10. Eating

4. Learning 11. Bowel functions

5. Breathing 12. Bladder functions

6. Reading 13. Digestive functions

7. Thinking


There needs to be a plan in place that all

teachers implement across the board.

Don’t rely on the student to request

accommodations “as needed”

10


Journal of School Nursing Article (Legal issues of 504 Plans, IEPS, IHPs after Concussion)

April 2015 Publication (Available online now)


Special

Education

www.brainsteps.net

Special Education Classification

Traumatic Brain Injury - (TBI)

Traumatic Brain Injury was added into the Special Education Law

(IDEA) in 1990 as a specific category requiring specialized understanding.

Public Law 101-476

[34 Code of Federal Regulations §300.7(c)(12)]


Fear of Faking Symptoms?

Does not occur often

District guidelines can be established

Caution advised when limiting school activities

www.brainsteps.net

Pennsylvania’s Statewide Brain Injury School Consulting Program

* BrainSTEPS provides consultation & training for students

who sustain all severities of brain injuries acquired anytime after birth


The BrainSTEPS Program

Created by:

PA Department of Health in 2007

Unique partnership for funding: PA Department of Health PA Department of Education, Bureau of Special Education via the PaTTAN network

Implemented by: Brain Injury Association of Pennsylvania

11


• 31 BrainSTEPS Teams cover the state of Pennsylvania

• 300+ Brain Injury school consultants

– Educational professionals

– Medical & Rehab professionals

– Family members


• 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 team member

Consultation

Activities

www.brainsteps.net

BrainSTEPS Teams monitor students

annually until graduation.

www.brainsteps.net

TBI

89%

nonTBI

11%

Students Referred to BrainSTEPS

CONCUSSIONS

77%

Moderate

& Severe

23%

TBI Severities


Pennsylvania’s Statewide

Return to Learn

Concussion Management Team (CMT)

Model


Common Student Concussion Scenario

1. Student returns to school

2. School may not implement accommodations

3. Symptoms flare

4. Student pushes through symptoms

5. Student waits for medical appointment 2 weeks away. Continues pushing through symptoms.

6. At appointment, Dr. may place student on homebound rest for period of time because at

this point, symptoms are so severe.

Return to Learn Concussion Management

Teams (CMTs) can alleviate these issues & potentially promote

faster student recovery

12


Return to Learn BrainSTEPS Concussion

Management Team (CMT) Model

–CMTs consist of 2 monitors • Academic Monitor (School Psych, Guidance Counselor)

Symptom Monitor (School Nurse)

–700+ Return to School Concussion Teams across the state of PA since Jan. 2013


Concussion Management Team (CMT)

CMT 1. Academic Monitor

2. Symptom Monitor Utilizes the Return to Learn

Concussion Electronic Toolkit

Symptom Monitoring Tool

1 page 1 side

Student Fills Out

Symptom Severity Rating Scale

Academic Monitoring Tool

1 page 1 side

Teachers Fill Out

Classwork, Homework, Tests, Assignments,

Behaviors


Concussion

Management Team

2 person CMT does NOT take the place of the

“Interdisciplinary Team” (Educational, Medical/Rehab, Parent, Student)

The CMT serves as the “Concussion Coordinators”

*CMTs are the Data Collectors & Information Gatherers


CMT Model Provides Pennsylvania School Districts:

1. Structure

Concussion Return to Learn Protocol

2. Online Return to Learn Training Best Practices for managing concussions in the

classroom

3. Tracking student progress Concussion Academic & Symptom Monitoring Toolkit

www.brainsteps.net

Student Concussion

CMT Monitoring @ School level 700+ Concussion

Management Teams for

Return to Learn

BrainSTEPS Support begins 4 weeks post @ Intermediate Unit level 31 Regional Consulting Teams

PA’s Layered Statewide Educational Infrastructure for Concussion Return to Learn


At 4 weeks post concussion:

Students are referred to BrainSTEPS &

A Concussion (mTBI)

Brain Injury Supports Framework

is created

13


BrainSTEPS Teams are not CMTs

CMTs are not BrainSTEPS Teams

• 29 educational Intermediate Units across Pennsylvania & 2 School Districts

• Consultation & Training for all severities of Acquired Brain Injuries

• 700+ across Pennsylvania based in school districts

• Taught to manage concussions (only) for the initial 4 weeks prior to making a BrainSTEPS referral

www.brainsteps.net

PA Students who should be referred to your regional Intermediate Unit BrainSTEPS Team

Type of Student Acquired Brain Injury Brain injury occurring anytime

AFTER birth

When to Refer a Student to BrainSTEPS www.brainsteps.net

Concussion

4 weeks post concussion unless student has a history of any of the following then refer sooner: • Prior concussions • Migraines • Learning, attention or emotional disabilities,

sleep disorders

New Moderate TBI, Severe TBI, Non-TBI

As soon as injury occurs, the sooner you refer the better. Don’t wait for the student to experience educational impacts/bad grades. Refer early to prevent issues.

Acquired Brain Injuries (TBI or non-TBI) that occurred in the past

If the student is experiencing educational impacts from an earlier brain injury, make a referral.


www.brainsteps.net

Concussion Management Team

Registration


The Centers for Disease Control (CDC) & Prevention document:

S. Davies, B. Eagan Brown,

G. Gioia, A. Glang, K. McAvoy

http://www.cdc.gov/concussion/pdf/TBI_Classroom_Tips_for_Teachers-a.pdf


Available for download at: www.brainsteps.net

Available to order in bulk at:

www.pattan.net


PaTTAN: www.pattan.net

TBI added as an “Educational Initiative” in 2012


14


The BrainSTEPS Program, PA Department of Health &

PA Department of Education invite your PA school to form & train a

Return to Learn Concussion Management Team (CMT)

Join the 700+ Return to Learn

Concussion Management Teams

that have formed in PA school districts

within the last 1.5 years

To register:

www.brainsteps.net


BrainSTEPS 2014 *Webinars will be archived at www.pattan.net & www.brainsteps.net

Return to Learn Concussion Series Wednesday, September 10, 2014

Medical Management of Concussion

3:30—5:00pm

Gerard Gioia, PhD

Wednesday, October 1, 2014

School Impacts, Return to School

Progression, Symptom Based Accommodations

3:30—5:00pm

Brenda Eagan Brown, MEd, CBIS

Wednesday, October 22, 2014:

Legal Dimensions for Schools

3:30—5:00pm

Perry Zirkel, PhD, JD, LLM

.

Wednesday, November 5, 2014 Vision Issues Impacting Academics 3:30—4:30pm Nathan Steinhafel, M.S., O.D., F.A.A.O

Wednesday, November 12, 2014 Vestibular Issues Impacting Academics

3:30—4:30pm Lenore Herget, PT, DPT, MEd

December 18, 2014 Supporting Emotional & Mental Health of Students with Protracted Recovery 3:30—5:00pm

David Brent, MD



concussions in pennsylvania - amazon s3€¦ · classwork, homework, tests, assignments, behaviors...

Documents