By Carolyn Rocchio

Treatment for cognitive functioning after brain injury

Cognitive rehabilitation is a “systemically applied set of medical and therapeutic services designed to improve cognitive functioning and participating in activities that may be affected by one or more cognitive domains” (Katz, Ashley, et al, 2006).

There is no longer any doubt about the effectiveness of cognitive and behavioral rehabilitation   following brain injury. However, insurance companies too frequently move patients with brain injury out of the medical model more rapidly for cost savings.  Children and youth comprise a very low percentage of those who receive any meaningful extended rehabilitation of functional impairments.  Most children and youth are discharged home to the care of parents and school systems.

Children are not “little” adults…their brains are still developing

During the developmental years, the child’s brain is not yet fully formed.  Nor is it as sophisticated as the brain of an adult.  In these developmental years which extend through the late teens and early twenties, children are expected to reach a number of milestones as they grow and mature.  A brain injury interrupts the normal developmental process.  This can subsequently have an impact on the child’s academic achievement and ability to socially interact with family and peers.  In most cases, the burden and responsibility of follow up care and remediation of the child’s deficits fall to parents and educators.

Parents are usually neither educated nor prepared to recognize and assess how the injury has affected their child’s learning capabilities and interactions within the family.  Yet parents ultimately become the case managers for their child’s follow-up services at school and in the community.  Educational systems vary significantly nationwide; however, all must comply with the Individuals with Disabilities Education Act which is the foundation for special education in all states. 

The student with a brain injury will have changing educational needs as the latent effects of the trauma to the brain emerge over time.   So it is important for educational programs for these students to include check points and flexibility to address the student’s emerging and developing special needs after an acquired brain injury.  Parents and educators can be most effective when they work as partners on behalf of the child and student. 

Cognitive rehabilitation for children requires special considerations

The following key factors must be considered when designing and providing cognitive rehabilitation for children and youth:

• Effects of the injury may be delayed; the younger the child when injured, the more likely that expected developmental milestones may be delayed or unattained.
• Youngsters with brain injuries need different approaches to learning to compensate for cognitive deficits in school.
• Increased guidance and cognitive models of rehabilitation can provide necessary checkpoints and flexibility to support optimal maturation when brain injury negatively impacts the child’s interactions with family and peers.
• Dual roles of parenting and case management increase stress for parents.  They require educational resources, information and support to successfully assist with the child’s transition from the medical and rehabilitation arena to the school system and community.

Transition from hospital to school after brain injury is critical

Ideally, day cognitive rehabilitation programs resembling school-like environments can provide children with individually designed approaches to academic achievement with feedback from therapists experienced in brain injury rehabilitation.  These programs facilitate the child’s transition from medical to school systems and the community.  This transition is critical as schools focus on learning and achievement, not on remediation of cognitive deficits.  A few hospital to school transition programs for children with acquired brain injuries exist within some large urban pediatric medical centers; however, overall their availability ranges from scarce to non-existent in local communities.  

Cognitive rehabilitation for children requires partnerships with parents and monitoring the brain injury’s effects on the child’s development and academic achievements.  The future holds the promise of greater interventions to enhance the progress of children with brain injuries. Research that is more focused on longitudinal studies can provide the information that will ultimately lead to the development of more comprehensive models of care for children with acquired brain injuries.

References

Katz, DI, Ashley, MJ, O’Shanick, GJ & Connors, S. Cognitive Rehabilitation: The evidence for funding and case for advocacy in brain injury. Retrieved January 16, 2009 from Brain Injury Association of America website at www.biausa.org/policyissues.htm.

Haarbauer-Krupa, J (2009).  Cognitive Rehabilitation for Children and Youth: Moving toward collaborative partnerships. Brain Injury/Professional 6(2) 20-22.

Recommended reading

This Fact Sheet is based on a special issue of Cognitive Rehabilitation: Efficacy and Best Practice of the Brain Injury/professional (vol. 6, issue 2) 2009.

Brain Injury/professional is the largest professional circulation publication on the subject of brain injury and is the official publication of the North American Brain Injury Society (NABIS). Brain Injury/professional is published jointly by NABIS and HDI Publishers.  Members of NABIS receive a subscription as a benefit of NABIS. Visit www.nabis.org to join.

Students and Brain Injury Recovery

By Marilyn Lash, M.S.W.

Lash and Associates Publishing/Training Inc.

The child’s brain is injured

An injury to a child can be an emotionally devastating event for families. Whether it is caused by a car crash, fall, sports injury or biking collision, many parents feel that have failed to protect their child from harm.

“Traumatic brain injury in childhood is the most prevalent cause of death and long term disability in children and affects all socioeconomic levels” (Bond Chapman, 2006).

How do children recover?

The recovery process for children with a brain injury is complex because the child’s brain is still developing. A new view of brain injury recovery in children describes two phases.

Immediate recovery phase

This is the time from the injury up to about one year. During this phase, the child may receive emergency medical treatment as well as intensive hospital care and rehabilitation with dramatic improvements in cognitive, motor and social skills. Because of this rapid change, families often bring their child home with the expectation of a full or almost complete recovery (Bond Chapman, 2006).

Latent recovery phase

This the period from one year after the injury to years later, even up to young adulthood. The full impact of an injury to a developing brain becomes apparent during this later phase (Bond Chapman, 2006).

Definition of neurocognitive stall

Dr. Chapman proposes that children with severe brain injuries are at risk for displaying a neurocognitive stall during the latent phase of recovery. She defines is as “…a halting or slowing in later stages of cognitive, social and motor development beyond a year after brain injury. Despite remarkable recovery during the first year after severe brain injury, children may appear to ‘hit a wall’ or ‘fail to thrive’ in terms of their continued cognitive growth. It is not so much that they lose already acquired skills as it is a failure or lag in development of later emerging cognitive milestones.” (Bond Chapman, 2006).

Children with severe brain injury are at greatest risk for a neurocognitive stall. With the lapse of time, they appear to grow into rather than out of their deficits. This often becomes evident during adolescence when the frontal lobes have rapid rates of growth and development from age 13 up to age 25 (Bond Chapman, 2006).

School work becomes more complex and so do social pressures with adolescence. These youth may have new difficulties keeping up with classmates and peers as they struggle to reach more complex cognitive levels in the classroom and with homework. The latent effects of earlier damage to the child’s brain emerge with time. Unfortunately, the link between an earlier injury to the child’s brain and emerging cognitive problems in school is often missed. When families and educators do not recognize the latent effect of a childhood brain injury, their behaviors are misidentified as symptoms of learning disability, ADHD or emotional disorders (Glang & Lash, 2004).

What does this mean for schools?

While there have been many advances and promising research in the acute care and rehabilitation of children with brain injuries, there has not been comparable progress in psychosocial and educational research on children. This population is underidentified and underserved in local schools.

“The challenge of addressing the latent developmental effects of childhood brain injuries is compounded by the fact that families often must assume the primary care giving role and schools often become the sole providers of rehabilitation services. Neither families nor educators have been systematically prepared or trained for this role, despite the inclusion of traumatic brain injury as a category under the Individuals with Disabilities Education Act in 1991″ (Glang & Lash, 2004).

So what can be done?

By taking a holistic approach, families and educators can be better prepared and develop the required skills to support and educate children with brain injury

Develop innovative approaches to family training

Families need information to build a knowledge base about their child’s brain injury. They also need home based training on strategies for managing their child’s cognitive, behavioral and physical challenges. Training must also include advocacy skills for negotiating services at school. It also requires preparing parents to manage services over the course of their child’s development and education. It is important to recognize the emotional trauma of parents and to help them develop coping skills, find support for grieving, and reduce caregiver stress (Glang & Lash, 2004).

Look at instructional strategies used with other student populations

Little research has been done on the effectiveness of educational strategies for students with traumatic brain injury. Yet there is a large body of research on effective instructional and behavioral strategies for students with other disabilities but similar functional challenges such as problems with attention, memory, impulse control, etc. This knowledge must be examined to determine how it can be applied and modified, if necessary, for students with brain injury. This approach builds on the strengths and skills of educators (Glang & Lash, 2004).

Build capacity of educational systems

Ongoing training and brain injury consulting teams are effective models for increasing the identification of students with brain injury and for providing educators with new strategies and skills (Glang & Lash, 2004).

Support parents as educational advocates

A child’s return to school after a brain injury introduces parents to an unfamiliar and confusing educational system involving special education and 504 plans. Training programs for parents of children with special needs have demonstrated that families can become effective advocates support, training and guidance. Parents of children with brain injury need comparable programs as well as mentors through other families (Glang & Lash, 2004).

References

Bond Chapman, S. (2006). Neurocognitive Stall: A paradox in long term recovery from pediatric brain injury. Brain Injury/professional 3(4), 10-13.

Glang, A & Lash, M. (2006). A Holistic Approach for Improving Educational Outcomes of Students with TBI: Promising practices and new directions for research. Brain Injury/professional 3(4), 16-18.

Recommended reading

This Fact Sheet is based on a special issue of Pediatrics and TBI of the Brain Injury/Professional (vol. 3, issue 4) 2006.

Brain Injury/Professional is the largest professional circulation publication on the subject of brain injury and is the official publication of the North American Brain Injury Society (NABIS). Brain Injury Professional is published jointly by NABIS and HDI Publishers.  Members of NABIS receive a subscription as a benefit of NABIS. Visit www.nabis.org to become a member.

Lash and Associates Publishing/Training, Inc. has a full line of manuals on educating students with brain injury in school.