Learning Outcomes An overview of this silent epidemic and misunderstood / ignored disorder and it s causes

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1 Services for Students with Traumatic Brain Injury: The Invisible Disability NAME 11 TH Conference October 8-11, 2013 Presented By: Michigan Traumatic Brain Injury Services and Prevention Council Members Jan Ashcraft, Oakland Schools ISD Tom Hildebrandt, Michigan POHI-SXI Conferences Kathi Clancy, COP ESD, School Social Worker Learning Outcomes An overview of this silent epidemic and misunderstood / ignored disorder and it s causes Understanding the family, school and community connections Recognizing the needs of students with TBI and how it impacts their learning Recommendations to school and family Looking at challenges to the systems providing services and identifying services that can be accessed and provided Identify three common causes of TBI for school age children Michigan TBI Services and Prevention Council Prevention Workgroup, Training Workgroup Online Modules 2 What is a Brain Injury? Acquired Brain Injury (ABI) An ABI is an injury to the brain that has occurred after birth and is not hereditary, congenital or degenerative. The injury commonly results in a change in neuronal activity, which affects the physical integrity, the metabolic activity, or the functional ability of the cell. The team does not refer to brain injuries induced by birth trauma. It includes TBI and injuries caused by an internal insult to the brain. Brain Injury Association of America (1997) Traumatic Brain Injury (TBI) TBI is an alteration in brain function, or other evidence of brain pathology, caused by an external force. Brain Injury Association of America (2011) 3 1

2 What is an Acquired Brain Injury? 4 4 Age Effects Children are just as vulnerable to traumas as adults. Children just don t bounce back after brain injury. Children may initially look well after a trauma. Effects of trauma may not be immediately apparent, as the child s brain is still developing. As the child gets older, that part of the brain previously damaged may not work as well as it should. 5 Brain Growth The greatest percentage of brain maturation occurs from birth through age 5 Before age 5 may be the most devastating time for a child to sustain an injury. This may be why infant and toddlers who have severe brain trauma from being shaken and impacted have such poor outcomes. Children with frontal lobe injuries early in life tend to develop long term-psycho-social and behavioral problems. 6 2

3 3 Types of Brain Injury Brain Injury will affect the student s education: MILD Brain Injury: largest group of TBI; most often misdiagnosed MODERATE Brain Injury: loss of consciousness; state of confusion SEVERE Brain Injury: prolonged unconsciousness; usually a coma 7 Mild Brain Injury 75% of all brain injuries are mild A mild brain injury also is known as a concussion Brief (less than 15 minutes) or NO loss of consciousness A dazed, vacant stare right after the injury Result in a normal neurological exam Often, people with mild brain injury do not even go to the hospital or seek any treatment Because signs and symptoms of mild brain injury are similar to other problems, it is often misdiagnosed. 8 Moderate Brain Injury A moderate brain injury is one that results in a loss of consciousness that can last minutes or a few hours and is followed by a few days or weeks of confusion. 9 3

4 Severe Brain Injury Severe brain injury almost always results in prolonged unconsciousness or coma lasting days, weeks or even longer. 10 Effects of TBI on a Student Coma Memory Disorder Reduced Stamina Headaches Vision Loss Muscle Spasticity Speech Impairments Attention & Concentration Alteration of Affect Amnesia Seizures Hearing Loss Intellectual Functioning Speech Functioning Academic Functioning Expressive & Written Language Problems 11 Effects of TBI on Student: Personality Problems Irritability Increased anxiety Impulsive and lacks inhibition More emotional Unmotivated Depression and Mood swings Socially inappropriate May not understand humor May not remember things just taught or directions given 12 4

5 Impact of TBI on Surroundings At School Demands are high Unattainable academic goals Cognitive and Social demands Withdrawn and Frustrated With Family Ability to Cope Increased Stressors Decreased success Family dynamics change Overall Denial of the symptoms/characteristics 13 partially because of TBI When the student returns to school Examine ALL possible avenues for service - OT, PT, SLI, SSW, Adaptive PE, Behavior Management, etc. Look at need at school-504 or Special Education for services Understand: Present condition and limitations Therapy requirements Medical equipment needed Self care plan Medications Communications and /or Behavioral concerns Current neurological status Need for Homebound Services if not ready to return to school building 14 Examples of Specific Accommodations Fatigue: Breaks, reduced schedule, shortened day, extended time Mobility: Re-enter slowly, early release, extra set of books for home Gross motor difficulties: Layout of school assign buddy, early release Fine motor difficulties: Scribe, outline or notes provided, books on tape Transitions: Minimal class changes, identification of community/post secondary supports Visual spatial deficits: Preferential seating, large print materials Technology: Access to computer with software, recorders for notes, phone Attention: Visual prompts, chunk assignments Memory deficits: Check off lists, visual schedule, frequent review of information, home-school notebook Organizational Skills: Color coded calendar, highlighted key information, trapper keeper 15 5

6 Seven Winning Ways to Behavior Plan Structure Consistency Repetition Be specific Practical Positively reinforce and often Must be meaningful to the person 16 Specialized Assessment & Treatment of Brain Injury Obtaining medical records might be the cheapest way to obtain documentation of TBI. Medicaid may pay for a neuropsychological exam for eligible persons if ordered by a physician. 17 Collaborate with Medical & Rehabilitation Systems Medical services are the beginning of the continuum of services necessary to support long-term needs of children with TBI. Important for local hospitals and schools to develop policies and procedures that promote effective communication and discharge planning. Referral systems that facilitate communication between hospitals, schools, and families increase chances of child receiving appropriate services. Children who are properly referred will be better managed, both medically and educationally. 18 6

7 TBI in the United States In America, 7 million people live with lifelong disabilities as a result of TBI. An estimated 1.7 million people sustain a TBI annually. Of them: 52,000 die, (1,520 die in Michigan) 275,000 are hospitalized, (10,980 are hospitalized in Michigan) million, nearly 80%, are treated and released from emergency departments (46,000 visit ERs in Michigan) TBI is a contributing factor to a third (30.5%) of all injury-related deaths in the United States. Over 98,000 Michigan residents are living with a TBI enough to fill the Big House! Note: Military TBI is not included in the statistics. 19 Recovery Measured in weeks, months and years Usually most rapid in the first six months Recovery from brain injury is slow and often incomplete No brain injury is too severe to lose hope, nor is any injury too mild to ignore!! 20 Costs of Traumatic Brain Injury Nationally traumatic brain injuries costs, in direct medical costs and indirect costs of TBI in the U.S., such as lost productivity, an estimated $76.5 billion. In Michigan our costs =$2.4 billion 21 7

8 Annual Number of TBI Cases in Michigan 1,520 Deaths 10,980 Hospitalizations 46,000 Treated & released from emergency departments??? Receiving other medical care or no care Note: Military TBI is not included in the statistics. 22 Fatal & Nonfatal Hospitalized TBI Cases by Age ( ) % of Cases Per TBI Grouping 16.0% 14.0% 12.0% 10.0% 8.0% 6.0% 4.0% 2.0% 0.0% Fatal TBI (n=12,160) Nonfatal, hospitalized TBI (n=87,849) Michigan Population 15% 15% 14% 14% 13% 13% 12% 11% 11% 11% 11% 10% 10% 10% 9% 9% 5% 2% 2% 2% 1% 1% < Age 23 Leading Causes of TBI ( ) Rank Fatal TBI Cases (n=12,160) Nonfatal, Hospitalized TBI Cases (n=73,277 cases with E-codes) 1 Suicide (30.2%) Accidental falls (46.3%) 2 Accidental falls (26.7%) (29.2%) 3 (20.0%) Assault-related (10.8%) 24 8

9 Fatal TBI by Main Cause of Injury ( ; n=12,160 cases) Unintentional Falls (n=3,247) 26.7% Self-harm/ (n=3,674) 30.2% Cause Assault/ (n=1,355) Vehicle Traffic (n=2,431) 11.1% 20.0% Unintentional Struck By/Against (n=91) 0.7% Other Causes (n=1,362) 11.2% 0% 5% 10% 15% 20% 25% 30% 35% % of TBI Fatalities 25 Leading Causes of Fatal TBI Males ( ; n=8,910 cases) Rank 0-4 (n=110) 5-14 (n=158) (n=1,245) (n=2,266 ) (n=2,522) 65+ (n=2,609) 1 Assault/ (34.5%) (50.6%) (36.8%) (46.5%) (45.9%) Accidental falls (50.9%) 2 (30.0%) Assault/ (18.4%) (21.8%) (16.9%) (30.8%) (26.8%) 3 Accidental falls (10.9%) (9.5%) Assault/ (23.3%) Assault/ (16.1%) Accidental falls (16.9%) (7.6%) 26 Leading Causes of Fatal TBI Females ( ; n=3,249 cases) Rank 0-4 (n=89) 5-14 (n=110) (n=352) (n=535) (n=609) 65+ (n=1,554) 1 Assault/ (48.3%) (62.7%) (59.1%) (29.9%) Accidental falls (25.6%) Accidental falls (73.1%) 2 (32.6%) Assault/ (10.9%) Assault/ (19.9%) (29.0%) (23.6%) (8.4%) 3 Accidental falls (3.4%) Unintention -al struck by/against (4.5%) Assault/ (22.6%) (11.6%) (22.0%) Assault/ (3.5%) 27 9

10 Nonfatal Hospitalized TBI Cases by Primary Source of Payment ( ; n=87,849) Other Govt. Payments 0.7% Self-pay/none 7.2% Others 2.1% Worker's Comp. 2.0% Medicaid 11.3% Private Insurance 42.3% Medicare 34.4% 28 Nonfatal Hospitalized TBI Cases by Hospital Discharge Disposition ( ; n=87,810) Other facility /hospital 5.2% Hospice 1.4% Left against medical advice 1.4% SNF, inpatient rehab, longterm care facility 22.3% Home w/ or w/out home health care/iv 69.7% 29 Medical Beneficiaries Receiving Services for TBI in Michigan, (FY ) FY2002 FY2003 FY2004 FY2005 FY2006 Distinct count of all Medicaid enrollees in Michigan Number of Medicaid enrollees (FFS & MHP*) receiving services for TBI (from mild to severe cases) Rate of TBI cases in Medicaid system per 1,000 Medicaid enrollees in Michigan 1,469,853 1,570,413 1,664,554 1,725,417 1,771,563 24,314 25,807 27,575 31,751 35, * FFS = Michigan Medicaid Fee for Service; MHP = Medicaid Health Plan 30 10

11 Medical Beneficiaries Receiving Services for TBI in Michigan, (FY ) Total number of Medicaid beneficiaries receiving services for TBI, FY Number of Medicaid Cases 129,153 % of TBI Medicaid Cases Medicaid cases with more severe TBI 16, % Non-hospitalized TBI Medicaid cases with or without emergency department visits 112, % 31 Medicaid TBI Cases by Sex (FY ) % of Cases Per TBI Grouping 60.0% 49.2% 51.7% 50.8% 48.3% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% 2005 Michigan All Medicaid Population TBI cases (n=129,153) 56.7% 51.0% 49.0% 43.3% Male Female More severe TBI cases Nonhospitali (n=16,242) zed TBI cases (n=112,911) 32 Medicaid TBI Cases by Age (FY ) 60.0% More severe TBI cases (n=16,242) % of Cases Per TBI Grouping 50.0% 40.0% 30.0% 20.0% 10.0% 20.6% 50.6% 14.2% 16.8% 10.0% 9.0% 13.8% 8.4% Nonhospitalized TBI cases (n=112,911) 2005 Michigan Population 16.2% 10.7% 9.8% 6.4% 4.7% 3.6% 3.2% 2.0% 0.0% Age Consistent with other findings on the incidence of TBI, the differences in age (t=82.49, p<.01) and sex (x 2 =184.86, p<.01) betw more severe and non-hospitalized cases were statistically significant

12 TBI Cost Information by Provider Category Medicaid FFS (only!) (FY ) Nursing homes/long-term care facility ($39,705,254.52) 40.1% Home health agency ($965,214.01) 1.0% Other claims ($5,108,690.51) 5.2% Hospital-inpatient facility cost ($43,318,687.26) 43.8% Professional services ($3,737,121.32) 3.8% Elderly and disabled waiver ($1,918,480.74) 1.9% Hospitaloutpatient (incl ED) facility cost ($4,144,856.50) 4.2% Total amount paid for TBI-related FFS claims from FY = $98,898, Special Education Students with TBI in Michigan Number of Special Education Students with (Identified) Primary Disability of TBI ( ) Number of students Source: MI - CIS Michigan Compliance Information System 36 12

13 Percent of Special Education Cases with (Identified) Primary Disability of TBI ( ) 0.35% 0.30% 0.25% 0.20% 0.15% 0.10% 0.05% 0.00% % 0.02% 0.12% 0.19% 0.23% 0.25% 0.27% 0.29% 0.28% 0.29% 0.29% % of Special Ed students Source: MI - CIS Michigan Compliance Information System 37 TBI Online Educational Courses Develop in 2005 via formative evaluation process by the TBI Council s Training Subcommittee launched 2006 Three FREE, self paced, State Continuing Education clock hours granted by the MI State Board of Education and others Online training includes: Traumatic Brain Injury and Public Services in MI, Pediatric Traumatic Brain Injury and Cognitive and Behavioral Consequences of TBI in Adults 38 Thank you for your attendance and interest in this almost invisible and misunderstood disorder References are in the hand outs. Have a good rest of your day! 39 13

14 Contact the Presenters Jan Ashcraft, Teacher Consultant for Students with Traumatic Brain, Oakland Schools Kathi Clancy, School Social Worker, Cheboygan-Otsego-Presque Isle ESD , ext. 307 Tom Hildebrandt, Self-employed