Bullying, detention and trips to the head’s office could all be signs that a school pupil has a brain injury. Others include falling grades, poor concentration and messing around in class.
By spotting these red flags and taking action, teachers can avert a downward spiral that all too often ends in the criminal justice system.
Rates of traumatic brain injury (TBI) in young people in custody range from 65 to 76%, compared to the general population of between 5 to 24%.
A 2010 study of incarcerated young offenders in the UK aged between 16 and 18, meanwhile, found that 65.1% reported a TBI that left them feeling ‘dazed and confused’.
As well as the lobby for criminal justice reforms to better handle brain injuries, campaigning of the education system is also underway.
Schools are being urged to improve their ability to identify brain injuries in children and make valuable interventions.
By doing so, they could positively change the outlook of young people on track for a life of limited opportunities or even behind bars.
Spreading the word among teachers is an uphill struggle, however, according to Louise Wilkinson, of the Child Brain Injury Trust (CBIT).
As the trust’s information and learning manager, she is charged with switching educators on to the signs of childhood brain injuries.
But apathy, misconceptions and overly officious school gatekeepers are common barriers in her quest.
The trust offers free workshops to educational professionals, showing them how to better recognise and support children with acquired brain injury (ABI).
Yet the response rate is extremely low. She recently sent a request to about 4,000 schools for attendees at an upcoming course, for example. Ten schools replied.
“You don’t know what you don’t know,” she says. “The frontline person who gets our email may delete it, assuming it’s irrelevant as they don’t have any kids with brain injuries. Unless they know of a child who’s had meningitis or been in an accident, they think it’s not for them.
“With the teachers that do come along, it’s like watching lightbulbs being switched on. Often they’ve worked with a child with learning difficulties that they just couldn’t put their finger on what the diagnosis should be. Sometimes they go back to work with a list of children whose backgrounds they intend to look into.”
Teachers trained to recognise brain injury signs face the challenge of distinguishing them from other conditions.
ADHD and autistic spectrum disorder (ASD) share lots of common ground with brain injuries; although TBI is around 30 times more common in young people statistically than those two conditions.
In young people in the general population, the rate of TBI – which excludes brain injury caused by illness (meningitis, epilepsy and measles), stroke, tumours, poisoning and lack of oxygen – is 24 to 31.6% (McKinley et al, 2008; McGuire et al, 1998).
This compares to 0.6 to 1.2% for autistic spectrum disorder and 1.7 to 9% for ADHD, CBIT says.
“There could be hundreds or even thousands of children that have been diagnosed with ADHD whose difficulties are actually as a result of an ABI,” Louise says.
“There are so many signs that are similar, and so many common areas of difficulties, but there are also some subtle differences. If professionals don’t know them, the child is probably not going to get the correct diagnosis.
“Children on the autistic spectrum can be obsessive and compulsive – and there may be no grey areas. Everything is black or white. They might also have difficulties with social skills and be awkward around people. But equally they might be very intelligent.
“Children with a brain injury may show similar signs. If they have frontal lobe damage they too may have difficulties with social interaction, understanding things and perception. A difference is that they may also have memory problems, whereas autistic children typically have very good memories.”
Unlike brain injury, conditions like ADHD and ASD are embedded in the training teaching professionals undergo, Louise believes.
ADHD’s higher profile in education circles is perhaps due to its regular media attention and the way diagnosis levels have exploded in the modern age.
Drug controversies, discrimination cases and classification changes have helped to keep the condition in the public eye in recent decades, certainly more so than childhood TBI.
Annual prescriptions in the UK for ADHD medications such as Ritalin more than doubled from 359,100 in 2004 to 922,200 in 2014. In the US, ADHD is now the second most frequent long-term diagnosis made in children, behind asthma.
Even among educational psychologists, training on identifying the fallout from brain injuries is poor. “In a two or three-year course, they tend to only have an hour or two focusing on brain injuries,” says Louise.
The impact of adolescence on young people’s behaviour also makes it difficult for school staff to recognise signs of brain injury. In these formative teenage years, long-forgotten childhood accidents can also re-emerge in the form of ABI-related problems.
“When children have accidents when they are little, parents are often told they’ve made a full recovery. However, maturation of the brain isn’t complete until a person is in their early to mid-20s. So sometimes things that are supposed to start working in adolescence suddenly don’t and issues are flagged up only then, years after the initial brain injury.
“If you bought a brand-new computer, but didn’t use a certain programme until six months later, you wouldn’t know whether or not that programme worked until then.
“We see particular problems when kids make the transition from key stages two to three [at age 11]. They’ve been going to the same classroom, sitting in the same chair, being taught by the same teacher every day.
“They know where the scrap paper is kept, and so on. Suddenly, at key stage three, they have lots of different teachers and lessons and have to navigate their way around school. They also have to remember what to take to school each day.
“The child who was fantastic in primary school and coped really well, suddenly has a high possibility of struggling with their organisational and planning skills, if they have a known or unknown brain injury.”
This change in circumstance can quickly develop into a downward slide in their performance at school.
“They end up wandering the corridors aimlessly. They can’t get their homework in on time. They get sent to detention and get admonished, but it’s not their fault. They are trying just as hard as they’ve always tried but everyone’s on their case.
“Then they start thinking ‘I might as well not bother’ and start playing up as no-one’s supporting them and it’s easier to get thrown out of the classroom. Eventually the school says they can’t cope with their behaviour and they get excluded.”
One young person quoted in a 2012 Children’s Commissioner’s report on neurodisability and young offenders, explained this frustrating experience: “I wasn’t able to concentrate…I got distracted easily…Then they just send you out and keep sending you out and sending you out and then you end up being sent home and then you get suspended.”
A fellow member of the same focus group said: “I went to junior school, I couldn’t read or write and they just gave me work I couldn’t do, telling me to do it, and I couldn’t do it, so instead of doing it I would just mess about.”
Another said: “My mum tried to get help but everyone said no. That left her with just me, not in school.”
From there, life can sink even deeper for some teenagers, with an inevitable slip towards petty crime and then more serious criminality. And whether they are in education or institutional rehabilitation the same problems can persist, plunging them into more trouble.
According to the Prison Reform Trust, a person with learning difficulties and disabilities can struggle to understand and adjust to rules and can become deemed a disruptive force.
Stopping this sad school-to-prison scenario from playing out up and down the country is an important part of CBIT’s work. As well as its continual programme of education for teachers, the group supports parents in getting children with brain injuries the extra help they may need at school.
Louise is motivated by personal experience. Her own son, now grown up, had difficulties at school and was initially dismissed as a naughty child.
He was eventually diagnosed with ADHD but it wasn’t until Louise was immersed in the world of childhood brain injuries with CBIT that she remembered her son’s accident.
He fell off a wall onto a concrete path at age two, throwing up afterwards, indicating concussion. He was observed for 24 hours and then it was assumed he had recovered.
Louise is unsure that his difficulties were connected to this rather than ADHD, but is certain that such experiences show the need for more transparency around children’s medical histories.
“We have a red book here in the UK that details a child’s medical history for the parents. But, unlike in other parts of the world such as Canada, the book is not used by the school system. It should be passed right the way through from primary to secondary education.”
Another systematic problem in the UK is the importance weighted on results, sometimes to the detriment of individual children.
“When you have a school that is very pupil-focused, they will move heaven and earth to support that child. We get very good results in those schools.
“Where you have a school that’s more concerned about their report from [government watchdog] Ofsted, they don’t want a failing pupil. They will not necessarily be as accommodating as other schools with requests for support and the child may end up changing schools.”
Tackling issues so ingrained in the education system is a tough ask for CBIT and its team of around 30. It hopes that by engaging more closely this year with local government, it will be able to exert more influence. It plans to carry out some “structured work” in one particular region of the country, working with a handful of education authorities.
See future issues of NR Times for an update on its success or otherwise.
Taking time to look back – so the way ahead is clearer
Reflective practice within healthcare settings is widely talked about, but not always so easy to implement in the workplace. NR Times speaks to one neurological centre about how it benefits patients and staff there.
Reflective practice and discussion in healthcare settings is a professional requirement for nurses, as laid out by the Royal College of Nursing revalidation requirements as part of their continuous professional development.
It allows professionals to take time to pause and reflect, communicate and plan, which undoubtedly leads to better outcomes for patients and staff.
But in reality, reflective practice can often be left to the bottom of the pile, underneath many of the competing responsibilities facing staff who are often pressed for time.
It could be argued that this is also why reflective practice is so important – healthcare staff are facing so many pressures that it actually makes less sense to neglect the important work of individual and team reflection.
The Royal College of Nursing defines reflective practice as: A conscious effort to think about an activity or incident that allows us to consider what was positive or challenging and if appropriate
plan how it might be enhanced, improved or done differently in the future.
Staff at Elysium St Neots Neurological Centre in Cambridgeshire started doing regular, weekly reflective practices when its new hospital director, Fiona Box, came into the role a few months ago.
The nurses and healthcare assistants from a ward are invited into the meetings and in their absence the therapy staff monitor patients and provide activities.
“We thought it would be helpful for team members to give them the opportunity to think, learn, and to hear their opinions,” says charge nurse Jemima Vincent.
“If we have an incident with a patient, we discuss it in the session” she says.
Sessions are led by the management team, with added input from psychology teams on each ward.
They will talk through any strengths, weaknesses and opportunities, and work through an analysis to learn from the incident and create an action plan.
They talk about the worst-case scenario in relation to an individual situation and discuss how staff would manage that, so they’re better prepared in the event of it happening.
While they focus on one patient at a time, issues arise during conversations that bring in their wider experiences.
In an article* published in the Nursing Times in 2019, Andrea Sutcliffe, chief executive of the Nursing and Midwifery Council said: “In these challenging times for health and social care, it’s so important that collectively we do all we can to support our health and care professionals, and their employers, in devoting time to individual, reflective, personal and honest thinking.”
Fiona has received encouraging feedback from staff, who say the meetings help the staff feel much more involved in a patient’s care and allow the team to increase their knowledge and understanding resulting in a more consistent way of working.
“Healthcare workers often don’t fully understand patients’ diagnoses or why they’re reacting in a certain way, for example,” Jemima says.
“They know a patient presents with certain behaviours and may be taking medicine to help them cope but they’re not aware why the patient is showing signs of aggression and the best response to deescalate the situation,” she says.
“It’s a learning opportunity for staff, because reflective practice means that they can understand a patient’s diagnosis and why they behave how they do,” Jemima says.
“Reflective practice answers their ‘why’ questions, and gives them a more open mind.”
Jemima also benefits from the meetings; it’s a way for her to get to know staff better, especially when it comes to learning opportunities.
“I’m able to understand what level of support each member of the team requires, including training needs and if they need more knowledge on a specific topic.”
In her final year as a mental health nurse student on extended clinical placement at Elysium St. Neots, Jo took part in a reflective practice session.
She had just finished her dissertation, in which she looked at how settings can increase the opportunities and variety of reflective practices within hospital settings.
The aim of Jo’s session was to reflect on the recent deterioration in a patient’s mental state and the resulting impact on their well-being to ensure staff had a consistent approach to support the patient.
The hospital’s director Fiona asked the team about the patient’s care plan, diagnoses and needs and wishes.
Where staff were unsure of the answers to questions, Jo says Fiona gave them answers and encouraged the team to share their knowledge of the patient, problem solve and come up with an agreed plan to move forward with.
Jo found the session helpful and was impressed with how the healthcare assistants were so involved in the discussions about all aspects of the patient’s care, including the more clinical elements.
Healthcare assistants told her they found the session helpful too and that it made them feel like they had a better understanding of the patient’s changing mental state, behaviours and needs.
Jo says having the opportunity to reflect on practice is a crucial skill for all healthcare workers to help them learn from their experiences and increase self-awareness, which, in turn, can improve individual professional standards, strengthen teams and enhance patient-centred care and clinical outcomes.
For referrals to Elysium St Neots Neurological Centre or other Elysium centres visit: www.elysiumhealthcare.co.uk/neurological
Reference source: https://www.nursingtimes.net/news/ professional-regulation/nmc-highlights-importance-of-nurses- reflection-on-practice-18-06-2019/
Robots and resilience at Askham Rehab
NR Times reports on a new rehabilitation approach taking place in Cambridgeshire.
Despite a year of relentless change and upheaval for all involved in neuro-rehab, one provider in Cambridgeshire has been able to keep its ongoing development on track.
Askham Rehab, part of the Askham Village Community, is a recently-launched specialist rehabilitation service incorporating the latest in rehab robotics and sensor assisted technology.
While the firm has invested in state-of-the-art technology to do the heavy lifting, however, its rehab services remain person-centred, as director Aliyyah-Begum Nasser explains.
“We’re a specialist rehab centre in essence, and so, although the robotic technology helps us to get the most out of our patients and staff, we are very much family-focused.
The equipment is obviously fantastic but we know from experience that a person’s mindset, and their ability to sustain whatever improvements they make, comes down to the people who are supporting them – their family members.
“We’ve been on some real journeys with many of our family members who just didn’t understand the impact of a brain injury in terms of how it can impact behaviour or what it can do for cognition.
“Once they understand that, suddenly they become a lot more compassionate, and a lot more supportive; they become part of the recovery process, rather than being a frustrated observer.”
With recognition of the family’s paramount importance to recovery, Askham Rehab does everything within its power to harness this force – including by enabling families to stay together in specially-designed apartments on site.
Aliyyah-Begum says: “The flats are fully adapted, with cantilever cupboards, height-adjustable sinks in the bathroom and full wet room with turning spaces.
“We have the patients themselves participating in rehab, specifically to their programme, but relatives are also there from the beginning, seeing the improvement and being part of our process from the outset.
“We think of the centre as more of a rehab environment; it’s not a just care home with therapy as an added extra.
“So from the minute our patients wake up to the minute they go to bed, everything is based around their recovery goals, and everyone is working together towards achieving them.”
And robotics are an important tool in pursuing these goals through patient exercise. They help therapists to achieve the repetitions and intensity needed to progress their clients, as Aliyyah-Begum explains.
“The point of the robotics is that they respond to the patient. For example, if you set the machine on a left lower limb, but it senses that there is more pressure being exerted through the right limb than the left, it will automatically respond to make sure the patient is moving the correct part of their body.”
The centre’s head of rehab and nursing, Priscilla Masvipurwa, says: “This is a real a game changer in our approach to rehabilitation.
“Robotics help to bridge the gap, increasing the frequency and repetitiveness of treatment, something that’s an essential part of the process.
“We anticipate that this will enable us to support our patients in reaching their goals in a more efficient and sustainable way.
“The centre has so far invested in four items from robotic rehabilitation firm Tyromotion, but is looking to add more over time, as the benefit to both staff and patients becomes ever more evident.
Aliyyah-Begum says: “It’s really important to the team at the centre that the robotics aren’t just seen as an add on.
“There is a lot of nervousness about robots replacing therapists, but our service is still very much therapy-led.
“What this means in practice is that, where a resident would previously have had maybe an hour of therapy time in an afternoon, now you have an hour of therapy time, and then you can carry on exercising if you want to, or carry on playing games with other residents.
“For example, one of our machines, the Myro, enables patients to play games like bat and ball, or perform virtual tasks like sweeping leaves.
“However, because it is all sensor-assisted, if it senses that the patient needs to work a certain hand, it will alter what it is asking them to do accordingly, while they won’t even necessarily feel they’re having therapy – it’s all part of the game, and part of their socialising with other residents.”
Askham Rehab forms part of the Askham Village Community, on the edge of Doddington village, in Cambridgeshire.
It provides specialist care for people of all ages, offering day visits, respite care and continuing long-term support, both on-site or at home.
The site consists of five homes, three of which are specialist neurological facilities. In total, the neuro-rehab team can look after up to 52 patients at any one time, with 120 staff made up of rehab professionals and specialists.
The team comprises carers nurses, physiotherapists, occupational therapists, speech and language therapists and psychologists.
Aliyyah- Begum believes that the introduction of the robotic rehab services, combined with the patient-led therapy the group has been offering for 30 years, can only enhance the centre’s outcomes.
She adds: “We know that there is an increasing number of care homes that offer specialist therapy, but the difference with Askham Rehab is that we have embedded it into the whole culture of our setting – and the outcomes really speak for themselves.
“We often discharge people earlier than planned, and that’s a testament to the fact that the patients are really working hard with the team throughout their stay with us to achieve their goals – and that is the key.”
For more information about Askham Rehab, visit www.askhamrehab.com
Astrocytes identified as master ‘conductors’ of the brain
In the orchestra of the brain, the firing of each neuron is controlled by two notes – excitatory and inhibitory – that come from two distinct forms of a cellular structure called synapses.
Synapses are essentially the connections between neurons, transmitting information from one cell to the other. The synaptic harmonies come together to create the most exquisite music–at least most of the time.
When the music becomes discordant and a person is diagnosed with a brain disease, scientists typically look to the synapses between neurons to determine what went wrong. But a new study from Duke University neuroscientists suggests that it would be more useful to look at the white-gloved conductor of the orchestra – the astrocyte.
Astrocytes are star-shaped cells that form the glue-like framework of the brain. They are one kind of cell called glia, which is Greek for “glue.” Previously found to be involved in controlling excitatory synapses, a team of Duke scientists also found that astrocytes are involved in regulating inhibitory synapses by binding to neurons through an adhesion molecule called NrCAM. The astrocytes reach out thin, fine tentacles to the inhibitory synapse, and when they touch, the adhesion is formed by NrCAM. Their findings were published in Nature on November 11.
“We really discovered that the astrocytes are the conductors that orchestrate the notes that make up the music of the brain,” said Scott Soderling, PhD, chair of the Department of Cell Biology in the School of Medicine and senior author on the paper.
Excitatory synapses — the brain’s accelerator — and inhibitory synapses — the brain’s brakes — were previously thought to be the most important instruments in the brain. Too much excitation can lead to epilepsy, too much inhibition can lead to schizophrenia, and an imbalance either way can lead to autism.
However, this study shows that astrocytes are running the show in overall brain function, and could be important targets for brain therapies, said co-senior author Cagla Eroglu, PhD, associate professor of cell biology and neurobiology in the School of Medicine. Eroglu is a world expert in astrocytes and her lab discovered how astrocytes send their tentacles and connect to synapses in 2017.
“A lot of the time, studies that investigate molecular aspects of brain development and disease study gene function or molecular function in neurons, or they only consider neurons to be the primary cells that are affected,” said Eroglu. “However, here we were able to show that by simply changing the interaction between astrocytes and neurons — specifically by manipulating the astrocytes — we were able to dramatically alter the wiring of the neurons as well.”
Soderling and Eroglu collaborate often scientifically, and they hashed out the plan for the project over coffee and pastries. The plan was to apply a proteomic method developed in Soderling’s lab that was further developed by his postdoctoral associate Tetsuya Takano, who is the paper’s lead author.
Takano designed a new method that allowed scientists to use a virus to insert an enzyme into the brain of a mouse that labeled the proteins connecting astrocytes and neurons. Once tagged with this label, the scientists could pluck the tagged proteins from the brain tissue and use Duke’s mass spectrometry facility to identify the adhesion molecule NrCAM.
Then, Takano teamed up with Katie Baldwin, a postdoctoral associate in Eroglu’s lab, to run assays to determine how the adhesion molecule NrCAM plays a role in the connection between astrocyte and inhibitory synapses. Together the labs discovered NrCAM was a missing link that controlled how astrocytes influence inhibitory synapses, demonstrating they influence all of the ‘notes’ of the brain.
“We were very lucky that we had really cooperative team members,” said Eroglu. “They worked very hard and they were open to crazy ideas. I would call this a crazy idea.”
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