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NeuroRehabilitation 34 (2014) 23–28 DOI:10.3233/NRE-131005 IOS Press
Pediatric cognitive rehabilitation: Effective treatments in a school-based environment Dorothy R. Shaw∗,1 Baltimore City Public Schools, Baltimore, MD, USA
Abstract. BACKGROUND: Many studies have investigated the impact of pediatric Cognitive Rehabilitation Therapy (CRT) upon intellectual functioning after traumatic brain injury; however, relatively few have identified efficacious treatment in a school setting. OBJECTIVE: The purpose is to present a variety of CRT strategies that would be useful to a teacher or therapist working with students who are learning disabled or who have who have had a traumatic brain injury (TBI). METHODS: This article investigates the particular challenges in learning which result from impaired cognition, and suggests techniques for improving memory and executive functioning. RESULTS: Students who are learning disabled or who have TBI face social and emotional issues that impact their learning. Special therapeutic interventions are necessary to assist with orienting to their setting, integrating with peers, and coping with distressing emotions. CONCLUSIONS: Students with TBI can adapt and flourish in a school based setting provided that therapies and learned strategies are targeted to their specific needs. Keywords: Emotion recognition, brain injury, nonverbal communication, cognitive rehabilitation
1. Introduction Traumatic Brain Injury (TBI) has become the leading cause of death and disability in children under the age of 15 (Sonnenburg, Dupuis, & Rumney 2010). Many of these children have learning difficulties resulting from acquired brain injuries which makes them eligible to receive special education services, or “individualized instruction”, under The Education of All Handicapped Children Act of 1975, reauthorized as IDEA in 1990. It is therefore necessary to provide this growing youthful population with effective therapeutic interventions in their school settings. However, there is a dearth of systematic research dealing with the efficacy of applied pediatric Cognitive Rehabilitation Therapy (CRT) in ∗ Address for correspondence: Dorothy R. Shaw, Baltimore City Public Schools, 502 Epsom Road, Baltimore, MD 21286, USA. E-mail: [email protected]. 1 Certified School Psychologist.
the school system. This review is intended to assess the literature on pediatric CRT and to suggest which types of treatments would be effective in school-based environments.
2. A brief review of pediatric CRT Parente, Vadiya, and Twari, (2012) provided a recent review of the literature on pediatric CRT. These authors found that CRT after pediatric TBI has focused on three aspects of cognition: Attention, memory, and executive functions. Regarding attention, the authors describe several recent studies that generally lead to the same conclusion (Butler & Copland, 2002; Van’t Hooft et al., 2005). These studies indicate that pediatric attention training does produce a significant improvement after brain injury. However, it is questionable whether the effect persists after therapy ends or how well the effect
1053-8135/14/$27.50 © 2014 – IOS Press and the authors. All rights reserved
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D.R. Shaw / Pediatric cognitive rehabilitation
generalizes to other aspects of the child’s daily living. Studies of memory training indicate that therapy to improve attention also improves word memory (Van’t Hooft et al., 2005). McCauley et al. (2010) reported significant improvement in memory for events with a group of children who received monetary incentives to perform relative to a matched group that did not. In general, these studies suggest that attention training, training to use prosthetic devices, or providing some tangible reward are efficacious treatment modalities after pediatric TBI. Several recent studies have assessed executive function deficits in pediatric samples after TBI (Semrud-Clikeman, 2010; Slomine et al., 2002; Nedabaum, 2007; Muscara, Catroppa, and Anderson, 2008; Selma, et al., 2008). Results indicate that pediatric populations with TBI experience deficits in inhibition, emotional control, and social skills which interfere with their quality of life to a greater degree than do their cognitive or physical deficits (Semrud-Clikeman, 2010). Persistence of executive difficulties in pediatric populations is a common theme in these studies; however, recent well-controlled intervention studies that were designed to evaluate treatment of executive dysfunction are conspicuously absent. Much of the studies of intervention involve small samples or single case designs (Feeney & Ylvisaker, 2003; Selznick & Savage, 2000). This type of study provides only mild support for the efficacy of interventions designed to improve executive functioning. The research summarized above is equivocal. Although most studies report significant improvement in cognitive functioning with treatment, there are few well-controlled studies that document improvement and even fewer that have been replicated. Most of the studies are single case or quasi-experimental designs and few, if any, report effect sizes. Semrud-Clikeman (2010) also observes that interventions may not be equally effective for children, adolescents, and young adults. Several predictors of return of function have been identified and replicated. For example, age at injury, family related variables, injury severity, and number of lesions the person sustains have all been implicated as useful predictors of return of functioning. Several therapies have been identified that show promise for treating attention (Sohlberg & Mateer, 1989), memory (McCauley et al., 2010), and executive function deficits after pediatric TBI (Klonoff et al., 2010). However, there are few standardized treatment protocols and it is not easy to replicate treatment procedures that are described in the articles. It is therefore
difficult to compare interventions, injury severity, lesion sites, or outcome measures across published studies.
3. The focus of school-based CRT - executive skills training Schools are the major agents of ongoing rehabilitation for these children, and schools must be equipped to provide the most effective learning environments. Students coping with the residual effects of head trauma require a multi-modal approach to learning which includes training insight and learning techniques in addition to coping skills and planning abilities (Klonoff et al., 2010). Students with TBI’s are returning to school with residual impairment in several different areas of intellectual processing. Perhaps the most important area of CRT with students concerns lack awareness of these impairments (Klonoff et al., 2010; Fuentes, McKay, & Hay 2010; Matheson 2010). Dawson & Guare (2010) assert that retraining executive skills is especially challenging for students with TBI because much of their attention is focused upon the present. At the same time, executive skills are necessary for the student to manage schedules, interact with peers and teachers, and navigate the school environment (Klonoff et al., 2010; Fuentes, McKay, & Hay 2010; Tsaousides & Gordon 2009; Semrud-Clikeman 2010; Matheson 2010). Executive skills are as important to being successful in school as are the intellectual skills required for gaining knowledge. There is no shortage of published literature that document the problems a student with TBI has in school. However, there are relatively few studies that suggest efficacious treatment for these problems or how to best accommodate the TBI student. What follows is a discussion of several techniques that the author has used with students in the Baltimore City School system and that have proven effective for treating students with TBI. 3.1. External aids Planning is a difficult skill for students with TBI. They are likely to be easily distracted; will spend much of their time orienting to their surroundings; they will have difficulty remembering where they are supposed to be and how to get there. Notebooks, planners and cuing devices increase the student’s level of attention (Tsaousides & Gordon, 2009), memory, and ability to plan. Students benefit from carrying a notebook to remind them of schedules, room numbers, locker numbers,
D.R. Shaw / Pediatric cognitive rehabilitation
and their teachers’ names. The notebook should also have a daily planner so that the student can see his or her daily schedule. Ideally, a beeping device such as a watch or cellphone could be programmed to alert them on the hour. The student learns to review the schedule each time the device beeps which would ensure at least 8–10 rehearsals of the information during the day. The student should also learn to record, review, or make changes or additions to the next day’s schedule the night before. This aspect to the child’s training teaches the value of rehearsal, holding facts in mind long enough to plan a strategy to complete their tasks, whereas the beeping watch cues the student to rehearse. Matheson (2010) describes “frontal lobe syndrome” as the students’ difficulty handling novel situations and making judgments about to which to attend. Notebooks allow the student to prioritize their tasks externally, to assign priorities to the tasks on paper, and to check them off when completed. This strategy will also help students to refocus attention to their priorities as they will have difficulty shifting between them. Other types of external aids are useful for promoting organization. For example, colored folders pertaining to each subject, separate notebooks with sections for classwork, homework, etc., or even separate book-bags for different days may be helpful. Tablet computers that can be programmed to present reminder messages at certain times to help the student recall what he or she should be doing during the day can be helpful. The student can also use his/her phone to take pictures of complex materials that may be presented on a blackboard during class. 3.2. Maps Not only must students remember facts they learn in class, but also daily routines, locations of their classes and materials, names of their classmates, and where to go in the school building. The students’ notebooks will be vital to their ability to cope with daily demands. School personnel should ensure that students have learned their environment, and are comfortable with their ability to navigate before expecting that they will be able to focus upon learning. Students may find it useful to develop their own map of the school building with key locations marked. Any strategy developed by the student for his or her own use will be more effective than a pre-developed strategy or cue handed to the student. Whenever possible, the therapist should also train the student to use the GPS directional system in his or her cellphone to help them navigate to places outside of the school or home.
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3.3. Functional mnemonics Tsaousides & Gordon (2009) investigated cognitive rehabilitation strategies for improving face-name associations, memory for past events, and memory of word lists and paragraphs. These authors endorsed the use of visual imagery, mnemonic strategies, and memory notebooks. Some of these mnemonics may be especially helpful with spelling or grammar. For example memorizing the rhyme “I before E except after C except for sounds like ahy as in neighbor or weigh” or “Your principal is your pal” can be used for spelling different types of words. Others, however, will be unique to the student. It is important to remember that the mnemonic must solve a problem for the student otherwise he or she will not use it. Mnemonics are cueing strategies. They are especially useful for helping students to recall facts. Word mnemonics are perhaps the easiest to construct. Each letter of the word cues the student to recall a particular aspect of the strategy in sequential order. For example, the word “READ” can be used to cue: (1) Review the assignment, (2) Explain in my own words, (3) Answer questions in back of chapter, (4) Diagram and outline. The therapist’s role is to teach students to spend their study time developing cues that help them recall the information on tests and in class. Rhyming mnemonics are the most memorable and word mnemonics are the easiest to construct. Those mnemonics the child develops will likely be the ones that he or she uses the most. The therapist should impress upon the student that the time spent developing mnemonics when studying is time well spent. 3.4. Expressive writing The ability to write clearly is both an art and a learned technical skill. Many students with brain injury are unable to write clearly because their ability to organize their thoughts is limited. Modern word processers ensure that most words in a written document are spelled correctly and that the grammar and punctuation are generally correct. However, word processors cannot organize the student’s thoughts and, all- to- often, their writing seems like a collection of unrelated facts. Training to write begins with training to outline and to sequence a person’s thoughts before actually writing sentences or paragraphs. The therapist begins by giving the student a topic then asking the student to provide three important points about the topic that could be elaborated further. For example, the therapist might propose
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“terrorism” as a topic and the student might respond 1) Jihadist, 2) Religious extremist, 3) Homeland security. These topics are then expanded into several others which eventually form the basis for the written document. It is important to impress upon the student that writing is like constructing a building. One puts up the frame of the building first (outline) then the sides and window (words). The building will not stand if it does not have a solid framing structure. There are several internet sites that can assist a student with TBI to construct their written documents. One particularly good site is www.grammarly.com. This site provides a thorough analysis of the student’s document and makes suggestions for improving the writing. It checks the document for literally thousands of grammar rules and also evaluates the document for possible plagiarism. The cost is minimal and the benefits include not only a well written end product but also the use of a software package that teaches good writing as the person uses it. 3.5. Social integration Students frequently experience significant isolation from their peer groups following injury; they are less likely to develop social and community integration skills common to their age group (Goyal & Keightley 2008). Erickson, Montague, & Gerstle (2010) reported that adolescents with severe TBI experience a lower behavioral quality of life than did students with orthopedic injuries. Children with cognitive deficits also reported significantly more physical or emotional problems following TBI (Sample, Tomter, & Johns 2007). Without adequate services in the community to facilitate children’s transition between hospital and home, it falls upon the schools to provide social re-integration. However, schools are often ill-prepared to provide these services. Sonnenburg, Dupuis, & Rumney (2010) showed that children with severe TBI are less skilled at problemsolving, and are less socially competent and lonelier than children with non-brain injuries. Therapy for social integration usually involves providing the student with behavioral scripts that are appropriate for different social settings. Most of these are common rules of etiquette such as holding a door open for a person, saying thank you, smiling and attending to social cues (Parente & Herrmann, 2010). More advanced forms of socialization training involve teaching the student to interpret body language and facial expressions and especially, prosody (see Bird and Parente, this issue). Much of this
work can be done in a group setting in which the participants practice carrying on conversations with one another or role-play potentially awkward social situations. Perhaps, the best way to train these skills is to video record the students’ conversations and then reinforce desired behaviors while the students watch the video. This type of training may be especially important when the child is in the midst of puberty. 3.6. Executive functioning 3.6.1. Disinhibition Students with TBI are often disinhibited. Treatment begins with rehearsal of rules, providing structure and external monitoring of behavior. The disinhibited student can be paired with another student who will monitor the TBI student’s behavior and correct it whenever possible. Often a cue word or non-verbal signal can be assigned that alerts the TBI student to inappropriate behavior. Role-playing of situations where the person is likely to be disinhibited and training to use a “stop and think” strategy in those situations may also be helpful. 3.6.2. Mental flexibility The ability to break set and to shift focus is also a problem for TBI students. Providing at least two well learned tasks and then requiring the student to shift back and forth between them provides practice with this skill. The tasks should be things the student does every day, for example, shifting back and forth between doing multiple choice reading comprehension questions and simple math computations. Scheduling regular times during the day when specific activities are performed forces the student to shift focus from one activity to another. Group therapy exercises can also be arranged where the members of the group engage in different conversations or activities and the topics change frequently in the course of the therapy interval. 3.6.3. Initiation and planning Difficulties with initiation of behavior are best treated with external prompts. Working in pairs with other students, establishing a buddy system for specific tasks, providing schedules that break the task down into small steps and provide dates for completion of each step can be especially helpful. Teaching the student how to create a “to-do” list and to organize the activities into groups that are “must do” and “should-do” can focus the student on those activities that are critical. Difficulties with planning involve teaching the student to break tasks down into subtasks and to structure
D.R. Shaw / Pediatric cognitive rehabilitation
a sequence of smaller goals that gradually completes the task. For example, planning to prepare a paper for a class involves researching the subject, preparing an outline, writing a draft, editing the draft, and preparing the final document. Training to prepare timelines for completing the various portions of the sequence is a critical part of planning. These should be written down preferably as a diagram. 3.6.4. Organization Training organization involves teaching both external and internal strategies. Several external aids for organizing behavior are discussed above. Internal strategies begin by teaching to the student to rehearse out loud. For example, when reading text materials the student should practice summarizing aloud what he or she has just read and as a rule, not go on to the next paragraph until the student can generate an adequate summary of the current one. Developing outlines for written documents trains the student to perceive the organization of the material. Some students may benefit more from drawing visual diagrams of materials they are trying to understand. Teaching the student to ask the question “How would I explain this information to someone else?” will force an internal organization. Most of these strategies are based on the principle that organization occurs at output (Parente & Herrmann, 2010). That is, techniques that force the student to say or do an activity also brings to light those aspects of the task that will require more rehearsal. It is similar to most teachers’ experience when they realize that they never understood a course’s content until they had to teach it. 3.6.5. Emotional issues Several studies have addressed the issue of students’ difficulty coping with their injuries after TBI (Klonoff et al., 2010; Tsaousdes & Gordon 2009; SemrudClikeman 2010; Matheson 2010). Many students are likely to spend much more time thinking about their feelings of anxiety and disorientation than thinking about how they are learning. Klonoff et al. (2010) discussed how helping students to accept their limitations, can also help them to adapt to their post-injury challenges. However, successful adaptation only comes about through self-awareness and willingness to try new methods of learning (Tsaousides & Gordon 2009). Semrud-Clikeman (2010) reported that disinhibition, aggression, anger, social deficits, and emotional problems can interfere with a TBI student’s long-term quality of life. Students must cope with the damage to
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their self-esteem that results from the feeling that they are no longer the person they used to be. They are suddenly unable to grasp material or remember facts as they once did. Their lack of immediate recall impairs their ability to orient to people, places, and things. Older students may react to their struggles with inhibition while young children exhibit more externalizing behaviors following TBI (Semrud-Clikeman 2010). Parents and professionals feel the duty to inform students of their errors in recall, and the students’ frustration increases by being told the obvious once again. Simply repeating the instructions, reviewing tasks, or providing a specific recall strategy can be quite helpful without causing defensiveness in the student. Semrud-Clikeman (2010) reported that traditional applied behavioral analysis and positive behavior supports have helped students to transition smoothly to home and school following in-patient rehabilitation. Matheson (2010) has studied neurobehavioral constructs in work rehabilitation, including mood and affect regulation, aggression regulation, impulse control, and coping with stress. Students who participate in work/study programs will be at risk for these problems and may benefit from individualized or group counseling to address those situations that are most likely to elicit an emotional response. Teaching a strategy for dealing with the situation, for example, counting to 10, walking away, deep breathing, can help diffuse the situations before they lead to an emotional outburst. Group discussion of techniques other members have used to diffuse their emotional response can also be helpful. Videotaping roleplaying situations in a group and discussing the video can be used to show students specific aspects of their behavior that exacerbate the interaction or diffuse it. Videos also illustrate specific non-verbal behaviors that signal emotionality.
4. Conclusions The purpose of this paper was to provide suggestions for improving memory and executive functioning of students with TBI who are returning to school. These suggestions are not exhaustive nor are they necessarily the best. They are simply techniques that have proven effective over the years with school-aged children in a large metropolitan school system. Ideally, these and other suggestions will eventually be aggregated into standardized treatment batteries with proven efficacy. Perhaps the first step towards this goal is to collect anecdotal treatments that have proven effective in real life
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settings that can eventually be evaluated to determine which have the greatest effect.
References Dawson, P., & Guare, R. (2010). Executive Skills in Children and Adolescents: A Practical Guide To Assessment and Intervention. Second edition. New York: The Guilford Press. Erickson, S. J., Montague, E. Q., & Gerstle, M. A. (2010). Health-related quality of life in children with moderate-to-severe traumatic brain injury. Developmental Neurorehabilitation, 13(3), 175-181. Fuentes, A., McKay, C., & Hay, C. (2010). Cognitive reserve in paediatric traumatic brain injury: Relationship with neuropsychological outcome. Brain Injury, 24(7-8), 995-1002. Goyal, A., & Keightley, M. L. (2008). Expressive art for the social and community integration of adolescents with acquired brain injuries: A systematic review. Research in Drama Education, 13(3), 337-352. Klonoff, P. S., Olson, K. C., Talley, M. C., Husk, K. L., Myles, S. M., Gehrels, J., & Dawson, L. K. (2010). The relationship of
cognitive retraining to neurological patients’ driving status: The role of process variables and compensation training. Brain Injury, 24(2), 63-73. Matheson, L. (2010). Executive dysfunction, severity of traumatic brain injury, and IQ in workers with disabilities. Work, 36, 413422. Parente, R., & Hermann, D. (2010). Retraining Cognition: Techniques and Applications. Austin, TX: Pro-ed. Sample, P. L., Tomter, H., & Johns, N. (2007). “The left hand does not know what the right hand is doing”: Rural and urban cultures of care for persons with traumatic brain injuries. Substance Use and Misuse, 42, 705-727. 2009;76:173-181. Semrud-Clikeman, M. (2010). Pediatric traumatic brain injury: Rehabilitation and transition to home and schooL. Applied Neuropsychology, 17, 116-122. Sonnenburg, L. K., Dupuis, A., & Rumney, P. G. (2010). Pre-school traumatic brain injury and its impact on social development at eight years of age. Brain Injury 24(7-8), 1003-1007. Tsaousides, T., & Gordon, W. A. (2009). Cognitive rehabilitation following TBI: Assessment to treatment. Mount Sinai Journal of Medicine, 76, 173-181.
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NeuroRehabilitation 34 (2014) 23–28 DOI:10.3233/NRE-131005 IOS Press
Pediatric cognitive rehabilitation: Effective treatments in a school-based environment Dorothy R. Shaw∗,1 Baltimore City Public Schools, Baltimore, MD, USA
Abstract. BACKGROUND: Many studies have investigated the impact of pediatric Cognitive Rehabilitation Therapy (CRT) upon intellectual functioning after traumatic brain injury; however, relatively few have identified efficacious treatment in a school setting. OBJECTIVE: The purpose is to present a variety of CRT strategies that would be useful to a teacher or therapist working with students who are learning disabled or who have who have had a traumatic brain injury (TBI). METHODS: This article investigates the particular challenges in learning which result from impaired cognition, and suggests techniques for improving memory and executive functioning. RESULTS: Students who are learning disabled or who have TBI face social and emotional issues that impact their learning. Special therapeutic interventions are necessary to assist with orienting to their setting, integrating with peers, and coping with distressing emotions. CONCLUSIONS: Students with TBI can adapt and flourish in a school based setting provided that therapies and learned strategies are targeted to their specific needs. Keywords: Emotion recognition, brain injury, nonverbal communication, cognitive rehabilitation
1. Introduction Traumatic Brain Injury (TBI) has become the leading cause of death and disability in children under the age of 15 (Sonnenburg, Dupuis, & Rumney 2010). Many of these children have learning difficulties resulting from acquired brain injuries which makes them eligible to receive special education services, or “individualized instruction”, under The Education of All Handicapped Children Act of 1975, reauthorized as IDEA in 1990. It is therefore necessary to provide this growing youthful population with effective therapeutic interventions in their school settings. However, there is a dearth of systematic research dealing with the efficacy of applied pediatric Cognitive Rehabilitation Therapy (CRT) in ∗ Address for correspondence: Dorothy R. Shaw, Baltimore City Public Schools, 502 Epsom Road, Baltimore, MD 21286, USA. E-mail: [email protected]. 1 Certified School Psychologist.
the school system. This review is intended to assess the literature on pediatric CRT and to suggest which types of treatments would be effective in school-based environments.
2. A brief review of pediatric CRT Parente, Vadiya, and Twari, (2012) provided a recent review of the literature on pediatric CRT. These authors found that CRT after pediatric TBI has focused on three aspects of cognition: Attention, memory, and executive functions. Regarding attention, the authors describe several recent studies that generally lead to the same conclusion (Butler & Copland, 2002; Van’t Hooft et al., 2005). These studies indicate that pediatric attention training does produce a significant improvement after brain injury. However, it is questionable whether the effect persists after therapy ends or how well the effect
1053-8135/14/$27.50 © 2014 – IOS Press and the authors. All rights reserved
24
D.R. Shaw / Pediatric cognitive rehabilitation
generalizes to other aspects of the child’s daily living. Studies of memory training indicate that therapy to improve attention also improves word memory (Van’t Hooft et al., 2005). McCauley et al. (2010) reported significant improvement in memory for events with a group of children who received monetary incentives to perform relative to a matched group that did not. In general, these studies suggest that attention training, training to use prosthetic devices, or providing some tangible reward are efficacious treatment modalities after pediatric TBI. Several recent studies have assessed executive function deficits in pediatric samples after TBI (Semrud-Clikeman, 2010; Slomine et al., 2002; Nedabaum, 2007; Muscara, Catroppa, and Anderson, 2008; Selma, et al., 2008). Results indicate that pediatric populations with TBI experience deficits in inhibition, emotional control, and social skills which interfere with their quality of life to a greater degree than do their cognitive or physical deficits (Semrud-Clikeman, 2010). Persistence of executive difficulties in pediatric populations is a common theme in these studies; however, recent well-controlled intervention studies that were designed to evaluate treatment of executive dysfunction are conspicuously absent. Much of the studies of intervention involve small samples or single case designs (Feeney & Ylvisaker, 2003; Selznick & Savage, 2000). This type of study provides only mild support for the efficacy of interventions designed to improve executive functioning. The research summarized above is equivocal. Although most studies report significant improvement in cognitive functioning with treatment, there are few well-controlled studies that document improvement and even fewer that have been replicated. Most of the studies are single case or quasi-experimental designs and few, if any, report effect sizes. Semrud-Clikeman (2010) also observes that interventions may not be equally effective for children, adolescents, and young adults. Several predictors of return of function have been identified and replicated. For example, age at injury, family related variables, injury severity, and number of lesions the person sustains have all been implicated as useful predictors of return of functioning. Several therapies have been identified that show promise for treating attention (Sohlberg & Mateer, 1989), memory (McCauley et al., 2010), and executive function deficits after pediatric TBI (Klonoff et al., 2010). However, there are few standardized treatment protocols and it is not easy to replicate treatment procedures that are described in the articles. It is therefore
difficult to compare interventions, injury severity, lesion sites, or outcome measures across published studies.
3. The focus of school-based CRT - executive skills training Schools are the major agents of ongoing rehabilitation for these children, and schools must be equipped to provide the most effective learning environments. Students coping with the residual effects of head trauma require a multi-modal approach to learning which includes training insight and learning techniques in addition to coping skills and planning abilities (Klonoff et al., 2010). Students with TBI’s are returning to school with residual impairment in several different areas of intellectual processing. Perhaps the most important area of CRT with students concerns lack awareness of these impairments (Klonoff et al., 2010; Fuentes, McKay, & Hay 2010; Matheson 2010). Dawson & Guare (2010) assert that retraining executive skills is especially challenging for students with TBI because much of their attention is focused upon the present. At the same time, executive skills are necessary for the student to manage schedules, interact with peers and teachers, and navigate the school environment (Klonoff et al., 2010; Fuentes, McKay, & Hay 2010; Tsaousides & Gordon 2009; Semrud-Clikeman 2010; Matheson 2010). Executive skills are as important to being successful in school as are the intellectual skills required for gaining knowledge. There is no shortage of published literature that document the problems a student with TBI has in school. However, there are relatively few studies that suggest efficacious treatment for these problems or how to best accommodate the TBI student. What follows is a discussion of several techniques that the author has used with students in the Baltimore City School system and that have proven effective for treating students with TBI. 3.1. External aids Planning is a difficult skill for students with TBI. They are likely to be easily distracted; will spend much of their time orienting to their surroundings; they will have difficulty remembering where they are supposed to be and how to get there. Notebooks, planners and cuing devices increase the student’s level of attention (Tsaousides & Gordon, 2009), memory, and ability to plan. Students benefit from carrying a notebook to remind them of schedules, room numbers, locker numbers,
D.R. Shaw / Pediatric cognitive rehabilitation
and their teachers’ names. The notebook should also have a daily planner so that the student can see his or her daily schedule. Ideally, a beeping device such as a watch or cellphone could be programmed to alert them on the hour. The student learns to review the schedule each time the device beeps which would ensure at least 8–10 rehearsals of the information during the day. The student should also learn to record, review, or make changes or additions to the next day’s schedule the night before. This aspect to the child’s training teaches the value of rehearsal, holding facts in mind long enough to plan a strategy to complete their tasks, whereas the beeping watch cues the student to rehearse. Matheson (2010) describes “frontal lobe syndrome” as the students’ difficulty handling novel situations and making judgments about to which to attend. Notebooks allow the student to prioritize their tasks externally, to assign priorities to the tasks on paper, and to check them off when completed. This strategy will also help students to refocus attention to their priorities as they will have difficulty shifting between them. Other types of external aids are useful for promoting organization. For example, colored folders pertaining to each subject, separate notebooks with sections for classwork, homework, etc., or even separate book-bags for different days may be helpful. Tablet computers that can be programmed to present reminder messages at certain times to help the student recall what he or she should be doing during the day can be helpful. The student can also use his/her phone to take pictures of complex materials that may be presented on a blackboard during class. 3.2. Maps Not only must students remember facts they learn in class, but also daily routines, locations of their classes and materials, names of their classmates, and where to go in the school building. The students’ notebooks will be vital to their ability to cope with daily demands. School personnel should ensure that students have learned their environment, and are comfortable with their ability to navigate before expecting that they will be able to focus upon learning. Students may find it useful to develop their own map of the school building with key locations marked. Any strategy developed by the student for his or her own use will be more effective than a pre-developed strategy or cue handed to the student. Whenever possible, the therapist should also train the student to use the GPS directional system in his or her cellphone to help them navigate to places outside of the school or home.
25
3.3. Functional mnemonics Tsaousides & Gordon (2009) investigated cognitive rehabilitation strategies for improving face-name associations, memory for past events, and memory of word lists and paragraphs. These authors endorsed the use of visual imagery, mnemonic strategies, and memory notebooks. Some of these mnemonics may be especially helpful with spelling or grammar. For example memorizing the rhyme “I before E except after C except for sounds like ahy as in neighbor or weigh” or “Your principal is your pal” can be used for spelling different types of words. Others, however, will be unique to the student. It is important to remember that the mnemonic must solve a problem for the student otherwise he or she will not use it. Mnemonics are cueing strategies. They are especially useful for helping students to recall facts. Word mnemonics are perhaps the easiest to construct. Each letter of the word cues the student to recall a particular aspect of the strategy in sequential order. For example, the word “READ” can be used to cue: (1) Review the assignment, (2) Explain in my own words, (3) Answer questions in back of chapter, (4) Diagram and outline. The therapist’s role is to teach students to spend their study time developing cues that help them recall the information on tests and in class. Rhyming mnemonics are the most memorable and word mnemonics are the easiest to construct. Those mnemonics the child develops will likely be the ones that he or she uses the most. The therapist should impress upon the student that the time spent developing mnemonics when studying is time well spent. 3.4. Expressive writing The ability to write clearly is both an art and a learned technical skill. Many students with brain injury are unable to write clearly because their ability to organize their thoughts is limited. Modern word processers ensure that most words in a written document are spelled correctly and that the grammar and punctuation are generally correct. However, word processors cannot organize the student’s thoughts and, all- to- often, their writing seems like a collection of unrelated facts. Training to write begins with training to outline and to sequence a person’s thoughts before actually writing sentences or paragraphs. The therapist begins by giving the student a topic then asking the student to provide three important points about the topic that could be elaborated further. For example, the therapist might propose
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“terrorism” as a topic and the student might respond 1) Jihadist, 2) Religious extremist, 3) Homeland security. These topics are then expanded into several others which eventually form the basis for the written document. It is important to impress upon the student that writing is like constructing a building. One puts up the frame of the building first (outline) then the sides and window (words). The building will not stand if it does not have a solid framing structure. There are several internet sites that can assist a student with TBI to construct their written documents. One particularly good site is www.grammarly.com. This site provides a thorough analysis of the student’s document and makes suggestions for improving the writing. It checks the document for literally thousands of grammar rules and also evaluates the document for possible plagiarism. The cost is minimal and the benefits include not only a well written end product but also the use of a software package that teaches good writing as the person uses it. 3.5. Social integration Students frequently experience significant isolation from their peer groups following injury; they are less likely to develop social and community integration skills common to their age group (Goyal & Keightley 2008). Erickson, Montague, & Gerstle (2010) reported that adolescents with severe TBI experience a lower behavioral quality of life than did students with orthopedic injuries. Children with cognitive deficits also reported significantly more physical or emotional problems following TBI (Sample, Tomter, & Johns 2007). Without adequate services in the community to facilitate children’s transition between hospital and home, it falls upon the schools to provide social re-integration. However, schools are often ill-prepared to provide these services. Sonnenburg, Dupuis, & Rumney (2010) showed that children with severe TBI are less skilled at problemsolving, and are less socially competent and lonelier than children with non-brain injuries. Therapy for social integration usually involves providing the student with behavioral scripts that are appropriate for different social settings. Most of these are common rules of etiquette such as holding a door open for a person, saying thank you, smiling and attending to social cues (Parente & Herrmann, 2010). More advanced forms of socialization training involve teaching the student to interpret body language and facial expressions and especially, prosody (see Bird and Parente, this issue). Much of this
work can be done in a group setting in which the participants practice carrying on conversations with one another or role-play potentially awkward social situations. Perhaps, the best way to train these skills is to video record the students’ conversations and then reinforce desired behaviors while the students watch the video. This type of training may be especially important when the child is in the midst of puberty. 3.6. Executive functioning 3.6.1. Disinhibition Students with TBI are often disinhibited. Treatment begins with rehearsal of rules, providing structure and external monitoring of behavior. The disinhibited student can be paired with another student who will monitor the TBI student’s behavior and correct it whenever possible. Often a cue word or non-verbal signal can be assigned that alerts the TBI student to inappropriate behavior. Role-playing of situations where the person is likely to be disinhibited and training to use a “stop and think” strategy in those situations may also be helpful. 3.6.2. Mental flexibility The ability to break set and to shift focus is also a problem for TBI students. Providing at least two well learned tasks and then requiring the student to shift back and forth between them provides practice with this skill. The tasks should be things the student does every day, for example, shifting back and forth between doing multiple choice reading comprehension questions and simple math computations. Scheduling regular times during the day when specific activities are performed forces the student to shift focus from one activity to another. Group therapy exercises can also be arranged where the members of the group engage in different conversations or activities and the topics change frequently in the course of the therapy interval. 3.6.3. Initiation and planning Difficulties with initiation of behavior are best treated with external prompts. Working in pairs with other students, establishing a buddy system for specific tasks, providing schedules that break the task down into small steps and provide dates for completion of each step can be especially helpful. Teaching the student how to create a “to-do” list and to organize the activities into groups that are “must do” and “should-do” can focus the student on those activities that are critical. Difficulties with planning involve teaching the student to break tasks down into subtasks and to structure
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a sequence of smaller goals that gradually completes the task. For example, planning to prepare a paper for a class involves researching the subject, preparing an outline, writing a draft, editing the draft, and preparing the final document. Training to prepare timelines for completing the various portions of the sequence is a critical part of planning. These should be written down preferably as a diagram. 3.6.4. Organization Training organization involves teaching both external and internal strategies. Several external aids for organizing behavior are discussed above. Internal strategies begin by teaching to the student to rehearse out loud. For example, when reading text materials the student should practice summarizing aloud what he or she has just read and as a rule, not go on to the next paragraph until the student can generate an adequate summary of the current one. Developing outlines for written documents trains the student to perceive the organization of the material. Some students may benefit more from drawing visual diagrams of materials they are trying to understand. Teaching the student to ask the question “How would I explain this information to someone else?” will force an internal organization. Most of these strategies are based on the principle that organization occurs at output (Parente & Herrmann, 2010). That is, techniques that force the student to say or do an activity also brings to light those aspects of the task that will require more rehearsal. It is similar to most teachers’ experience when they realize that they never understood a course’s content until they had to teach it. 3.6.5. Emotional issues Several studies have addressed the issue of students’ difficulty coping with their injuries after TBI (Klonoff et al., 2010; Tsaousdes & Gordon 2009; SemrudClikeman 2010; Matheson 2010). Many students are likely to spend much more time thinking about their feelings of anxiety and disorientation than thinking about how they are learning. Klonoff et al. (2010) discussed how helping students to accept their limitations, can also help them to adapt to their post-injury challenges. However, successful adaptation only comes about through self-awareness and willingness to try new methods of learning (Tsaousides & Gordon 2009). Semrud-Clikeman (2010) reported that disinhibition, aggression, anger, social deficits, and emotional problems can interfere with a TBI student’s long-term quality of life. Students must cope with the damage to
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their self-esteem that results from the feeling that they are no longer the person they used to be. They are suddenly unable to grasp material or remember facts as they once did. Their lack of immediate recall impairs their ability to orient to people, places, and things. Older students may react to their struggles with inhibition while young children exhibit more externalizing behaviors following TBI (Semrud-Clikeman 2010). Parents and professionals feel the duty to inform students of their errors in recall, and the students’ frustration increases by being told the obvious once again. Simply repeating the instructions, reviewing tasks, or providing a specific recall strategy can be quite helpful without causing defensiveness in the student. Semrud-Clikeman (2010) reported that traditional applied behavioral analysis and positive behavior supports have helped students to transition smoothly to home and school following in-patient rehabilitation. Matheson (2010) has studied neurobehavioral constructs in work rehabilitation, including mood and affect regulation, aggression regulation, impulse control, and coping with stress. Students who participate in work/study programs will be at risk for these problems and may benefit from individualized or group counseling to address those situations that are most likely to elicit an emotional response. Teaching a strategy for dealing with the situation, for example, counting to 10, walking away, deep breathing, can help diffuse the situations before they lead to an emotional outburst. Group discussion of techniques other members have used to diffuse their emotional response can also be helpful. Videotaping roleplaying situations in a group and discussing the video can be used to show students specific aspects of their behavior that exacerbate the interaction or diffuse it. Videos also illustrate specific non-verbal behaviors that signal emotionality.
4. Conclusions The purpose of this paper was to provide suggestions for improving memory and executive functioning of students with TBI who are returning to school. These suggestions are not exhaustive nor are they necessarily the best. They are simply techniques that have proven effective over the years with school-aged children in a large metropolitan school system. Ideally, these and other suggestions will eventually be aggregated into standardized treatment batteries with proven efficacy. Perhaps the first step towards this goal is to collect anecdotal treatments that have proven effective in real life
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settings that can eventually be evaluated to determine which have the greatest effect.
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cognitive retraining to neurological patients’ driving status: The role of process variables and compensation training. Brain Injury, 24(2), 63-73. Matheson, L. (2010). Executive dysfunction, severity of traumatic brain injury, and IQ in workers with disabilities. Work, 36, 413422. Parente, R., & Hermann, D. (2010). Retraining Cognition: Techniques and Applications. Austin, TX: Pro-ed. Sample, P. L., Tomter, H., & Johns, N. (2007). “The left hand does not know what the right hand is doing”: Rural and urban cultures of care for persons with traumatic brain injuries. Substance Use and Misuse, 42, 705-727. 2009;76:173-181. Semrud-Clikeman, M. (2010). Pediatric traumatic brain injury: Rehabilitation and transition to home and schooL. Applied Neuropsychology, 17, 116-122. Sonnenburg, L. K., Dupuis, A., & Rumney, P. G. (2010). Pre-school traumatic brain injury and its impact on social development at eight years of age. Brain Injury 24(7-8), 1003-1007. Tsaousides, T., & Gordon, W. A. (2009). Cognitive rehabilitation following TBI: Assessment to treatment. Mount Sinai Journal of Medicine, 76, 173-181.
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