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Best Practices in Cognitive Rehabilitation for Children and Youth

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Juliet Haarbauer-Krupa, PhD, Brain Injury Professional magazine

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Parents and caregivers are critical partners

An important practice is to partner with the child’s family. Children do not live in isolation but rather in the context of the family unit. Early in recovery parents are the best sources of information about the child’s preinjury medical history, school achievement and approaches to learning, social functioning, and goals for adulthood. Following medical treatment for a brain injury, parents and caregivers become the primary case managers of children’s care as they move from the medical to the educational system. Parents convey pertinent medical information from rehabilitation to the schools. The large degree of variability in parenting practices, supervision, and reaction to the stress and burden of a catastrophic injury further complicates case management of children’s services and outcomes. Models that stress longitudinal monitoring of progress provide an opportunity to monitor aspects of parent and family factors that contribute significantly to child outcomes. Education and support for parents and caregivers about the potential for long-term effects of the injury is crucial.

Injury adjustment is part of the process

As children proceed through recovery, the changes in cognitive skills from their previous level of functioning become apparent in school and the community. Effective cognitive rehabilitation programs integrate opportunities for self-evaluation of performance and feedback in protected settings. This style of therapy is rarely accomplished in a school-based model whose focus is on learning and achievement rather than remediation of processes and developing self-awareness of performance. Both parents and children are adjusting to changes in the child’s cognitive skills and behavior. Best practices accommodate and guide this adjustment.

Transitions between service models require planning and communication

Approaches incorporating medical care with educational transitions are effective with assisting children moving from the medical to the educational model, particularly early in recovery. Programs that provide educational liaisons and develop schoolrelated strategies as part of medically based treatment bridge the gap between the medical and educational models of care. Day rehabilitation programs that simulate a school-like environment in a medical setting are rare but valuable transition services for children leaving the hospital following brain injury. In these types of programs, children have a chance to approach academic materials and receive feedback on their performance from experts in therapy and educational interventions relatively early in the recovery phase prior to returning to school.

Look to principles of learning and development

At later levels of recovery and for many years after the injury, direct instruction and compensatory strategy teaching are methods that hold promise to meet the increasing requirements for independence as the child progresses through school. Researchers report efficacy of these approaches based on child learning principles and use in other populations of children with disabilities (Glang, Ylvisaker, Stein et al., 2008). These two aspects show promise for extending what may be termed cognitive rehabilitation in the medical setting to instructional practices for children in the schools.

A reexamination of cognitive intervention after acquired brain injuries in children is in order. Evolution of new models of care integrating principles of medically based cognitive rehabilitation into the child’s environment of school and community programs as well as providing methods to monitor the child’s progression in their development through transition to adulthood is needed. Cognitive rehabilitation for children requires partnership with families and monitoring of the injury effects on development in progress and academic achievement outcomes. This effort requires collaboration between medical, school and community services to assure appropriate interventions for the child’s stage of development and career goals.

Future Directions

Because children currently spend so little time in the medical model following their injury, it is critical that professionals educate health payors about the unique needs of children and at the same time develop approaches to apply the principles of cognitive rehabilitation to the environment where children spend the most time. The best practice is to build collaborative models of cognitive rehabilitation for children that join families, medical facilities, schools, and community services to track the child’s progress and intervene when required through the transition to adulthood. Research investigations examining children longitudinally after a brain injury are instrumental with developing comprehensive models of care for children following a brain injury.


Anderson, V., & Catroppa, C., Advances in postacute rehabilitation after childhood-acquired brain injury: A focus on cognitive, behavioral and social domains. American Journal of Physical Medicine and Rehabilitation, 85, 767-778, 2006.

Butler, R.W., Copeland, D.R., Furlough, D.L., Mulhern, R.K., Katz, E.R., Kazak, A.E., et al., A multicenter randomized clinical trial of a cognitive remediation program for childhood survivors of a pediatric malignancy. Journal of Consulting and Clinical Psychology, 76:367-378, 2008.

Cicerone, K.D., Dahlberg, C., Malec, J.F., Lagenbahn, D.M., Felicetti, T., Kneipp, S., et al., Evidence- based cognitive rehabilitation: Updated review of the literature from 1998 through 2002. Arch Phy Med Rehabil, 86:1681-1691, 2006.

Di Scala,C., Osberg, & Savage, R.C., Children hospitalized for traumatic brain injury: Transition to post acute care. J Head Trauma Rehabil, 12, 1-10, 1997.

Glang, Ann., Ylvisaker, M., Stein, M., Ehlhardt, L., Todis, B., & Tyler, J., Validated instructional practices: Application to students with Traumatic Brain Injury. J Head Trauma Rehabil, 23: 243-251, 2008.

Katz, D. I., Ashley, M.J., O’Shanick, G.J. & Connors, S., Cognitive Rehabilitation: The evidence for funding and case for advocacy in brain injury. Retrieved January 16, 2009 from the Brain Injury Association of America website at www.biausa.org/policyissues.htm, 2006.

Kinsella, G., Prior, M., Sawyer, M., Murtaugh, D., Eisenmajer, R., Anderson, V., Bryan, D., & Klug, G. (1995). Needs of children and adolescents following traumatic brain injury. J Head Trauma Rehabil, 339-351.

Laatsch, L., Harrington, D., Hotz, G., Marcantuono, J. Mozzoni, M.P., Walsh, V., & Hershey, K.P., An evidence-based review of cognitive and behavioral rehabilitation treatment studies in children with acquired brain injury. J Head Trauma Rehabil, 22: 248-256, 2007.

Taylor, H.G., Yeats, K.O., Wade, S.L., Dotard, D., Stain, T. Mont petite, M., Long-term educational interventions after traumatic brain injury in children. Rehabilitation Psychology, 48: 220-247, 2003.

Ylivisaker, M., Hanks, R., & Johnson-Greene, D., Perspectives on rehabilitation of individuals with cognitive impairment after brain injury: Rationale for reconsideration of theoretical paradigms. J Heard Trauma Rehabil, 17 : 191-209, 2002.

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.

Juliet Haarbauer-Krupa, PhDJuliet Haarbauer-Krupa, PhD, Juliet Haarbauer-Krupa, PhD has 30 years of clinical experience in brain injury and has developed various pediatric rehabilitation programs. She is a researcher/speech pathologist at Children's Healthcare of Atlanta and adjunct faculty, Department of Pediatrics, Emory School of Medicine.

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Comments [1]

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Apr 4th, 2013 6:49am

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