Case Study: IPP Team Develops Rehabilitation Transition Plan for High School Student Following a Traumatic Brain Injury

Work Setting: Health Care Work Setting: Schools Work Setting: Private Practice

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Meet the Team

Rehabilitation-Based Team

• Kai and His Family
• Physiatrist
• Brain Injury Case Manager
• Audiologist
• Speech-Language Pathologist
• Occupational Therapist
• Physical Therapist (Inpatient & Outpatient)
• Neuropsychologist
• Education Specialist/School Liaison
• Clinical Psychologist

School-Based Team

• Kai and His Family*
• School Administrator*
• School Speech-Language Pathologist*
• School Guidance Counselor*
• School Psychologist
• School Nurse*
• Classroom Teachers*
• SAT Coordinator

*mTBI Management Team Members

Background

Kai is a 16-year-old right-handed high school student who was a backseat passenger involved in a motor vehicle accident during the fall semester of his junior year. He sustained multiple leg and facial fractures as well as an mTBI with brief loss of consciousness. Kai has no memory of the accident or the events immediately leading up to it. His MRI was negative for any overt brain bleed. However, he required several orthopedic and plastic surgeries and was hospitalized for 3 weeks before being transferred to an inpatient rehabilitation facility for 4 weeks to address his physical strength, balance, mobility, and ongoing symptoms of mTBI.

Planning for Kai’s return home and return to school began soon after his admission to the inpatient rehabilitation facility. Staff from Kai’s high school, including members of its previously established mTBI management team, were invited to the inpatient interprofessional rehabilitation team meetings, which Kai’s supportive family also attended. This helped to ensure that everyone was on the same page about Kai’s plan of care and progress. During the last 2 weeks of his rehabilitation stay, Kai began to keep up with some of his studies (as much as he was able to tolerate) with the help of the facility’s education specialist, who communicated with Kai’s teachers and school counselor.

Although concerned about how he would navigate the school environment, academic demands (e.g., new learning, reading textbooks, listening while writing notes, test-taking), social interactions, and extracurricular activities, Kai and his family were looking forward to his return to high school. He initially returned to school part time while attending outpatient therapies, and he gradually transitioned to a full day of academics and an eventual discharge from outpatient services.

Kai has no pre-existing attention, learning, or sensory disabilities; no history of depression/anxiety; and no prior brain injuries. He does have a history of migraines. Kai is most concerned about the impact his injury will have on his ability to complete all the requirements for his junior year and take his SATs so that he is on track for high school graduation and college as planned. Kai’s family and friends are extremely supportive and have been instrumental in helping him implement strategies, remain compliant with medical appointments and medications, and get to and from therapy sessions and school on time.

How They Collaborated

Prior to Kai’s return home, teachers, support personnel, and administrators from Kai’s high school attended an educational session by the rehabilitation staff to learn more about mTBI and Kai’s specific physical, cognitive, and communication profile. Strategies to support and accommodate Kai in the home, school, and community environments were discussed at length with his extended family and closest friends who would be taking part in his recovery, as well as with the school staff. Collaborative goal setting occurred through motivational interviewing with Kai and his family to identify challenges and to develop meaningful goals for his return home and to school.

Upon discharge from inpatient rehabilitation 7 weeks post-injury, Kai continued to experience leg weakness from his fractures and symptoms of mTBI—including fatigue, headaches, sensitivity to light/noise, sleep disturbances, irritability, poor concentration, slower recall and processing, and executive dysfunction. The interprofessional teams from the inpatient rehabilitation facility and the school, including Kai and his family, decided that he would begin outpatient therapies (working with a physical therapist [PT], speech-language pathologist [SLP], and clinical psychologist) while initially attending school on a part-time basis per a well-defined, graduated mTBI return-to-learn protocol. Through a 504 plan, the school team also put into place formalized academic accommodations and environmental modifications based upon all therapists’ recommendations and team discussions. Kai agreed to be responsible for monitoring his own symptoms and sharing any challenges, successes, and revised goals as they arose. All involved were aware that intervention strategies would require modifications over time based on Kai’s progress (e.g., as symptoms flared or resolved, and as school demands increased). The high school’s SLP consulted with the school-based mTBI management team to monitor the effectiveness of the return-to-learn plan, developing and assisting with implementation of new strategies, assistive technologies, or accommodations moving forward.

Outcome

Initially, Kai’s return to school was part time, with graduated introduction of classwork and homework, and with extra breaks during the day as he steadily increased his tolerance for all academic activities and caught up on his learning. Kai’s return-to-learn process also included independent daily check-ins and symptom reporting with the school nurse and/or his guidance counselor, along with regular classroom observations and monitoring by various members of the school-based mTBI team to verify his self-report.

When Kai was discharged from outpatient PT and SLP services, he was ready to return to school full time with his full academic schedule. Following discussions between the medical and school-based interprofessional teams, all team members determined that Kai’s 504 plan was meeting his needs and that no referral for evaluation for full special education support was warranted. He was nearly independent in the use of assistive technologies and other strategies to help with his organization, time management, and other cognitive communication needs and was walking without a cane. Kai’s balance and coordination were improved to the point that he was able to navigate the school halls safely while using a backpack. He had learned to incorporate accommodations and to self-advocate for environmental modifications as needed. Kai continued to work with his physician as well as his outpatient and school-based psychologists and counselors to address management strategies for headaches, sleep, and anxiety.

By the fourth quarter of his junior year, Kai was completing assignments on time, engaging in lectures and notetaking, maintaining his pre-injury grades, hanging out with friends, and slowly returning to extracurricular activities. He had taken his SATs with accommodations and was looking forward to applying to colleges and returning to a full-time academic schedule in his senior year.

Ongoing Collaboration

The school-based team reached out to the neuropsychologist and clinical psychologist rehabilitation team to (a) ask any questions that arose about next steps in their return-to-school protocols for adolescents with mTBI and (b) identify the best options for coordinating services and continuing care moving forward for Kai, his family, and any future students should the need arise. During early communications, the rehab team reminded school personnel that adolescents with mTBI often experience latent challenges, especially as academic and cognitive-communication demands increase; therefore, they stressed the importance of monitoring Kai over time—not just during his initial return to school—and adjusting plans accordingly.

The rehab-based SLPs and the school-based SLP remained in contact by email or phone to discuss Kai’s ongoing needs. Contact was frequent at first and then was reduced to an as-needed basis to ensure successful transition to school and successful academic outcomes. The remainder of the school year, Kai’s school based SLP consulted with various school staff and administrators—including the school nurse, classroom teachers, guidance counselor, school psychologist, and SAT coordinator—to discuss a team approach and adjustment to any necessary accommodations that supported Kai’s return to school, SAT preparation and administration, and completion of requirements for his junior year. The neuropsychologist” and “clinical psychologist” also remained in close contact, with consent from Kai and his family.

The school-based team planned to meet with Kai and his family toward the end of summer to reevaluate the need for a 504 plan during his senior year as opposed to implementing more informal academic accommodation and modification plans. 

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