School-Based Cognitive Interventions for Children with Postconcussional Disorder.

Children with postconcussional disorder face unique challenges when moving from the rehabilitation setting to the education setting. Diagnostic criteria of postconcussional disorder are reviewed. Stages of the recovery process are described. Sample educational interventions are identified for cognitive deficits associated with attention, memory, organization and problem solving.

The neuropsychological sequelae following a traumatic brain injury (TBI) can be devastating for both the patient and the family. Approximately one million children sustain a TBI each year, which represents approximately one-sixth of all pediatric hospital admissions (Batchelor & Dean, 1996).

Postconcussional disorder is a syndrome that follows from a traumatic brain injury that involves a cerebral concussion sufficiently severe to result in the loss of consciousness (Kaplan & Sadock, 1998). The concussion can come from either a penetrating wound, which usually leads to highly localized brain damage; or from a blunt force trauma, which usually leads to diffuse axonal shearing and injury.

The brain trauma of postconcussional disorder is usually precipitated by a pedestrian-automobile collision or a playground accident. Most children with postconcussional disorder will withdraw from school while participating in a hospital rehabilitation program. After short-term recovery is established, these children usually return to their school. As a result of the concussion, these children often experience a significant worsening of school or academic performance dating from the trauma.

Teeter and Semrud-Clikeman (1997) indicate that the consequences of an acquired brain injury have not been adequately researched, which is particularly problematic given that an acquired brain injury is considered a separate handicapping condition requiring special education support. Consequently, school personnel face the challenging task of assisting with the rehabilitation health-care plan while, at the same time, developing an individual education plan that will assist with the child's adjustment to the school environment.

Symptoms

Children with postconcussional disorder often experience one or more of the following symptoms: (1) a period of unconsciousness lasting for more than 5 minutes after the brain trauma, 2) a period of posttraumatic amnesia lasting for more than 12 hours, and 3) a new onset of seizures that occurs within the first 6 months after the injury (American Psychiatric Association [APA], 1994). Symptoms of this disorder can include fatigue, disordered sleep, headaches, dizziness, irritability or aggression, anxiety, depression, affective lability and apathy. The incidence rate for boys varies from 150 to 200 per 100,000 prior to age 5, and increasing to 400 per 100,000 at age 15; while the incidence rate for girls varies from 100 to 170 per 100,000 prior to age 5, and increasing to 300 per 100,000 at age 15 (Batchelor & Dean, 1996).

Purpose

The purpose of this article is to review a sample of classroom interventions available to school staff when treating cognitive symptoms associated with postconcussional disorder. The article focuses exclusively upon school-age children having experienced blunt force postconcussional disorder; and does not discuss symptoms associated with penetrating injuries to the brain, where outcomes are more predictable and influenced by the site of the lesion (Sellars, Vegter & Ellerbusch, 1997). The interventions described in the article do not necessarily generalize to children with shaken-impact syndrome, which usually results in a more significant intellectual impairment; and the interventions do not necessarily generalize to children with cognitive symptoms associated with such medical conditions as stroke, aneurysm or tumor.

Recovery Process

The course of recovery for the child varies according the site and extent of injury; however, the recovery typically involves three stages (Corbett & Ross-Thomson, 1996). Stage 1 recovery often includes displays of agitation, impulsivity, and confusion. Often, the child shows impaired efficiency of information processing. This stage is usually apparent in the rehabilitation setting, but can also occur in the schools. Children in Stage 2 recovery often show an intolerance for stimulation, with a denial of cognitive disability and with increasing behavioral demands made upon the teachers and caregivers. Often, the child displays disinhibition and may emit behaviors that seem inappropriate and immature. Children in Stage 3 recovery begin to show an increasing understanding of the nature and type of cognitive deficits associated with the brain injury along with an understanding of the lasting nature of these deficits. Consequently, children in the third stage often become susceptible to anxiety, depression, frustration, and anger.

At each stage of the recovery process, the child with postconcussional disorder experiences some deficits of cognitive functioning that were not apparent at preinjury. These cognitive impairments include varying degree of impairments in attention, memory, organization and problems solving. The degree of intervention depends, in part, upon the stage of recovery, with more advanced recovery requiring less intensity of educational support. In most cases, interventions that target specific aspects of cognitive disability can assist the child's reintegration into the school.

Attention Deficits

Children with postconcussional disorder often have difficulty encoding material presented in class and have difficulty attending to instructional stimuli for extended periods of time. This difficulty becomes exasperated if the instruction requires divided attention or rapid alternating shifts from one instructional set to another. These children often seem easily distracted and have difficulty staying focused on task. They may perseverate on specific topics or activities, and often become easily frustrated with activities that require sustained attention to complex stimuli.

Environmental adaptations should reduce distracting stimuli and include a quiet learning environment, with seating assignments made to locations of least distraction (Pearson, 1985). Ideally, the classroom can provide a quiet corner or a study carrel for use if the child becomes fatigued, irritated, or anxious. Many times, a child with this disorder will benefit from the use of white noise or soft, nonstimulating rhythmic music in the background.

Instructional services that provide cues, props, and prompts can assist the child's ability to recognize topic headings and relevant information, and the teacher's use of verbal and visual cues can help the child develop skills in self-cueing (Sellars & Vegter, 1997). Instruction delivered in shorter learning units, with short breaks between units, can often keep the child's attention directed to instructional stimuli. Transitional statements when moving between each learning unit will help the child maximize sustained attention, and previewing the specific unit's purpose and anticipated time line will help the child retain a learning set. The use of multiple modalities (e.g., auditory, visual, and tactile) when presenting explanations can help direct and focus the child's attention.

Children can participate in the training of their own attention span. Special previously agreed-upon verbal and non-verbal cues between teacher and students can provide valuable feedback to the students that assists their ability to begin the self-monitoring of behavior. Fixed time-interval self-observations allow children with beginning opportunities of evaluating the direction of their own attention. Subsequent discussion of these self-observations with the teacher provides opportunities of identifying those internal and external conditions antecedent to behaviors. By engaging in a functional assessment and discussion of this behavior, children becomes more sensitive to the conditions that help and hinder sustained attention to instructional stimuli and contribute to the overall self-regulation and self-management of attentional processes.

Memory Deficits

Children with postconcussional disorder have difficulty with the storage and retrieval of information presented to them in the classroom setting. The interaction of deficits in attention and memory makes it difficult for children to learn new academic material (Corbett & Ross-Thomson, 1996). Often times, children have difficulty recalling the directions required for completion of classroom assignments and may forget to complete or turn in their assignments. Many times, children have difficulty recalling new information from reading assignments and oral presentations.

Memory deficits can involve verbal and visual memory systems, which implicates a need to present new information across multiple modalities of learning (Corbett & Ross-Thomson, 1996). For example, pictorial representations of verbal material can assist some children with impaired verbal memory, while verbal explanations of graphs and charts can assist students with a visual memory impairment. Having the child practice repetition of orally presented information (e.g., sentence repetition) can strengthen verbal memory, and showing the child a picture of an object for a few seconds and than asking the child to recall specific attributes of that picture can strengthen visual memory. By providing verbal descriptions of visual material, the child learns strategies of verbally mediating visual stimuli, which assists the child's ability to recall information (DeBoskey, 1996).

Children with postconcussional disorder can also participant in their own memory training exercises. Repeating a series of numbers through use of chunking strategies can develop skills in immediate auditory recall. Retelling a story can help develop skills in listening comprehension and verbal recall. Using a book reading strategy of prereading-reading-reviewing can strengthen ability to organize and recall written material. Talking with the teacher or counselor about interesting daily and weekly events can strengthen episodic memory.

Organizational Skills

Children with postconcussion disorder often experience difficulties with orientation and organization (Corbett & Ross-Thomson, 1996). Usually, after short-term recovery is complete, disorders of orientation are resolved, and the child is appropriately oriented to time, place, and person.

However, lingering difficulties with organization often persist, and the child may experience difficulties with understanding cause and effect, similarities and differences, and actions and consequences. The child may have difficulty sequencing objects into linear or temporal order as well as categorizing these objects into groups. Often times, the child with deficits in organizational skills cannot discriminate relevant from irrelevant material and has difficulty outlining and summarizing instructional material (DeBoskey, 1996).

Children with deficits in organizational ability can benefit from a structured environment in which teachers teach metacognitive strategies in how-to-learn new material. For instance, teaching a strategy such as SQ3R (viz., survey, question, read, recite, and review) helps the child organize the encoding and storage of written material, and teaching a strategy of subvocalizing important words used in a teacher's lecture helps the child encode and store orally presented information. Previewing the day's schedule and reviewing the day's assignment helps the child construct an organizational framework. Discussing and mapping the daily routines can help create the mind set of a predictable environment. Giving extra explanations at transition points during the day can assist the child disengage and reengage into the instructional material. Providing a study buddy or peer partner can assist the child when making transitions between assignments (Pearson, 1995).

Children can facilitate their learning through use of assignment sheets and mnemonic devices. The use of a tape recorder or a calendar-of-reminders and can provide students with beginning self-management strategies of planning and monitoring their own performance. Many children with postconcussion disorder have particular difficulty with organizing and maintaining one's work space; therefore, periodic time spent in organizing the desk helps the child construct their own personal learning environment.

Problem solving skills

Children with postconcussional disorder have difficulties with problem-solving activities (Corbett & Ross-Thomson, 1996). Often, these children have difficulty recognizing the essential ingredients and seeing the big picture of presenting problems. These children often experience much difficulty generalizing acquired skills to new yet similar situations. Despite adequate component skills, children with this disorder have difficulty stringing together component skills and frequently have difficulties with problems requiring sequential problem solving.

The teacher can assist the child by breaking down complex tasks into specific steps and then listing the sequence necessary for successful completion of the task. The use of smart-charts can provide the child with a mnemonic strategy when facing complicated tasks. Reducing the length of an assignment can give the child success with component tasks, with successive incremental lengthening of assignments when the child is ready. Having the child complete an errand helps develop organization and problem solving skills, with subsequent discussion of strategies used to plan, initiate, monitor and self-correct the errand's completion. Many times, the child can benefit from a contractual agreement, with reinforcement based on student effort.

Children can improve their problem solving abilities by discussing with teachers or counselors those academic tasks they find most difficult and by identifying the component skills needed to correctly resolve presenting problems. By discussing problem solving experiences with others, children acquire an ability to self-monitor and self-regulate their problem solving strategies. Both academic and social problem solving topics can be discussed, yet the focus is upon the identification and sequencing of component skills needed for problem resolution. In addition, children benefit from using verbal self-statements that provide assurance and strategy when facing new and unexpected problem situations. Children with postconcussional disorder usually benefit from organizational strategies that sort problems into activities of (a) problem forming, (b) problem solving, and (c) solution using.

Conclusion

The long term consequences of postconcussional disorder will vary greatly, depending upon the site and extent of injury. In the most optimistic sequelae, the child shows full recovery and can participate in education with the same level of support that was in place at preinjury. More frequently, however, some extra educational support is needed as long term gradual improvements are made in the cognitive functions of attention, memory, organization and problem solving.

The health care plan that follows a child from the rehabilitation setting to the education setting only gives a general estimate of the rate and course of recovery, and seldom addresses specific cognitive interventions in the classroom. Usually, the child returning from rehabilitation has completed the process of short term recovery and is beginning a more lengthy process of long term recovery. While some children may complete long term recovery within one or two years, many children will need continued educational support throughout their formal education. Therefore, professional education staff need to construct an individual educational plan that is flexible and modifiable with the hope that eventually the child will at some point no longer need extra educational support. However, for many children, there remains a need to provide specific interventions targeted to specific cognitive deficits in attention, memory, organization and problem solving.

References

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.

Batchelor, E. S., & Dean, R. S. (1996). Pediatric neuropsychology: Interfacing assessment and treatment for rehabilitation. Boston: Allyn and Bacon.

Corbett, S. L., & Ross-Thomson, B. (1996). Educating students with traumatic brain injuries: A resource and planning guide. Madison, WI: Wisconsin Department of Public Instruction.

DeBoskey, D. S. (1996). An educational challenge: Meeting the needs of students with brain injury. Houston, TX: HDI Publishers.

Kaplan, H. I., & Sadock, B. J. (1998). Synopsis of psychiatry (8th ed.). Media, PA: Rose Tree Corporate Center.

Pearson, S. (1995). Classroom strategies: Responding to student changes. In G. Wolcott, M. Lash, & S. Pearson (Eds.). Signs and strategies for educating students with brain injuries: A practical guide for teachers and schools. (pp. 39-52). Houston, TX: HDI Publishers.

Sellars, C. W. & Vegter, C. H. (1997). Pediatric brain injury. Houston, TX: HDI Publishing.

Teeter, P. A., & Semrud-Clikeman, M. (1997). Child neuropsychology: Assessment and interventions for neurodevelopmental disorders. Boston: Allyn and Bacon.

Bruce F. Dykeman, Ph.D., Associate Professor, Department of Counseling and Human Services, Roosevelt University.

Correspondence concerning this article should be addressed to Dr. Bruce F. Dykeman, Associate Professor, Department of Counseling and Human Services, Roosevelt University, 430 S. Michigan, Chicago, IL 60605. E-mail: [e-mail].