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Juliet Haarbauer-Krupa, PhD, Brain Injury Professional magazine (page 1 of 3) Page 1 of 3
Moving toward collaborative partnerships
Introduction
Cognitive rehabilitation has long been known as an effective intervention practice for remediation of the cognitive and behavioral deficits following brain injuries and strokes (BIAA, 2006; Butler, Fairclogh, Katz, et al., 2008; Cicerone, Dahlberg, Malec, et al., 2005; Laatsch, Harrington, Hotz, et al., 2007). By definition, cognitive rehabilitation is a “systematically applied set of medical and therapeutic services designed to improve cognitive functioning and participating in activities that may be affected by difficulties in one or more cognitive domains” (Katz, Ashley & O’Shanick, 2006). Cognitive rehabilitation follows recovery from a brain injury. In the early phase of recovery, cognitive remediation programs facilitate skill return and provide family education. In later phases of recovery, return to an independent lifestyle is a primary goal with efforts targeted to compensatory strategy training. Theoretical models of cognitive rehabilitation propose a systematic, goal directed approach to improved optimal functioning in school, community and home. Different philosophical and service delivery approaches form the concept of cognitive rehabilitation, with some advocating for skill-based intervention and others proposing compensatory strategy training. Both approaches have merit in children’s programs.
Recent investigations about cognitive intervention in a medical setting demonstrated effectiveness of a skill based approach for academic skill improvement for acquired brain injuries (Butler et al., 2008). However, beyond the initial medical treatment, children with acquired brain injuries spend very little time in the medical model of cognitive rehabilitation. In the last several years, changes in medical insurance coverage result in either denial or restriction of services. After medical treatment for a brain injury, the majority of children go home to their parents, schools and communities and only a small portion of children remain hospitalized for rehabilitation services (Di Scala, Osberg, & Savage, 1997). In this study, 75% of the children who displayed functional impairments were discharged to home without an active rehabilitation program and less than 2% were referred for educational assistance at school. A similar trend occurs in the state of Georgia following emergency room visits for TBI. Since 2004, approximately 19,000 visits are reported each year in the Georgia Central Registry for children under age 19, with the majority of children discharged home to the care of parents. The percentage of children from this injury count classified as Traumatic Brain Injury in the annual Georgia Department of Education Count approximates 2%. Both sets of figures contrast with research reports of a special education placement rate of 62-79% for moderate to severe injuries when hospitalized children are tracked following discharge ( Kinsella, Prior, Sawyer, et al., 1995; Taylor, Yeates, Wade, et al., 2003). A number of reasons account for the discrepancy in reporting, including lack of incidence figures documenting the rate of cognitive impairment in the total population of children seen in emergency rooms for TBI and difficulty tracking children receiving services in other educational categories at school. For children who need continued services following medical treatment, a heavy burden of care falls on the family, community, and school services.
Children are more likely to spend most of their recovery period in the schools, a system that is becoming the long-term rehabilitation program for children and youth. School system models focus on learning needs, and “maintaining” a child in an educational program. These mandates differ significantly from medical models that strive for optimal recovery and improved quality of life. Proposals for more “ecologically based” approaches which deliver cognitive rehabilitation in the child’s environment of home, school and community have the potential to effectively extend intervention beyond the medical model and bridge the gap between both models of service for children (Anderson & Catroppa, 2006; Ylvisaker et al., 2002).
Consensus about children’s outcomes following brain injury is that impairments in cognitive and behavioral skills impact educational and social functioning. Younger children and children with more severe injuries are particularly vulnerable to long-term cognitive impairments. Developmental expectations for preschool children are dramatically different from teenagers who have already acquired a larger foundation of developmental milestones and knowledge. For children injured at a younger age, problems can change in severity and scope over time as development proceeds. A model that incorporates checkpoints along the developmental continuum to track the impact of cognitive impairments on school achievement and social participation and determine efficacy of intervention is appropriate for children.
Best practices for cognitive rehabilitation for children and youth
Several key factors comprise the best practices for cognitive rehabilitation for children and youth.
Children are different from adults
Compared to adults who sustain a TBI, children’s cognitive impairments affect the ability to achieve developmental milestones not previously attained, impact school achievement, and restrict the ability to participate in age appropriate social and extracurricular activities. Effects of the brain injury may be delayed, especially for young children. As they proceed through development, children and their parents may be unaware of the need to change direction in approaches to learning and interaction due to cognitive impairments. Unique issues for children require models of cognitive rehabilitation to provide checkpoints and flexibility.
From Brain Injury Professional, the official publication of the North American Brain Injury Society, Vol. 6, Issue 2. Copyright 2009. Reprinted with permission of NABIS and HDI Publishers. For more information or to subscribe, visit: www.nabis.org.
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. Brain Injury Professional is published jointly by NABIS and HDI Publishers. Members of NABIS receive a subscription to BIP as a benefit of NABIS membership. Click here to learn more about membership in NABIS.
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