212 Practice Issues in School Neuropsychology

have significant and direct impact on the residual functional capacity of the I child. Additionally, the invasiveness of the intervention (e.g., surgery) may I impact the specific area of the tumor as well as surrounding areas in the brain, I Brain tumors are often associated with global cognitive decline, deficits in I function associated with frontal cortex, nonverbal abilities, visual-motor skills, I attention and concentration, processing speed, and memory (Armstrong, I Blumberg, & Toledano, 1999). Armstrong et al. also note that deficits may I emerge in the years following treatment, rather than immediately.

Effects of Cancer Treatment

Chemotherapy and radiation involve several noxious physical effects includ- I ing nausea/vomiting, fatigue, mouth sores, hair loss, growth retardation, and I endocrine difficulties, along with the longer-term effects of a decrease in I cognition, academics, visual-motor skills, attention, short-term memory, and I a higher incidence of learning disabilities (Li & Wendt, 1998; Reinfjell et al., ■ 2007). Espy et al. (2001) followed children with acute lymphoblastic leukemia I (ALL) who had been treated with prophylactic chemotherapy and found I modest declines in math skills, verbal fluency, and visual-motor integration I abilities, as well as deficits in visual-motor skills that appeared to persist at I four years post treatment.

School Reintegration After Cancer Treatment

Prolonged treatment necessitates the early involvement of the school. Stu- I dents may be provided with home/hospital instruction since consistent I communication among the family, school, and medical team ensure appro- I priate recommendations and services. Teachers and peers, with parental I consent, may be provided education about the child's condition, treatment, I and prognosis/expected effects. Once back in the classroom, specific instruc-И tion in skills to strengthen attention/memory and organizational strategies, I as well as social skills support, are recommended. Specific academic modifi- I cations may be beneficial in reducing limitations imposed by physical side I effects (e.g., decreased writing expectations, oral exams, increased time for I assignments, calculator use). A comprehensive neuropsychological evalua- I tion may delineate student strengths and areas of weakness that will require I educational accommodations and modifications. Long-term follow-up infor- I mation for educators will increase their knowledge and awareness of residual I effects that may only emerge once the student encounters more cognitively I demanding work (Li & Wendt, 1998). Armstrong et al. (1999) suggested I repeated evaluations at twelve- to eighteen-month intervals, specifically I including measures of attention, concentration, memory, visual-spatial and I

School Reentry for Children Recovering from Neurological Conditions 213

visual-motor, fine motor, and processing speed skills. They also suggested

lit curriculum-based or performance based measures may also identify

children whose academic growth potential is not progressing as it was prior

tomedical treatment. These measures can also interface with more traditional

neuropsychological measures.

TRAUMATIC BRAIN INJURY (TBI)

A reported one million children/adolescents experience a TBI each year Jremont, Mittenberg, & Miller, 1999), with 15- to 24-year-olds falling at greatest risk (Hooper et al., 2004). TBI may result from multiple etiologies hduding falls, assaults, sporting events, and motor vehicular accidents |^VAs) (Hooper et al., 2004; Tremont et al., 1999). Two types of damage jMy result from TBI: closed and open head injuries. In a closed head injury, the brain bounces off the bony structures within the skull. This movement may lead to shearing of nerve fibers and blood vessels, which can lead to [knorrhages and swelling in the brain (Rotto, 1998). Open head injuries occur ■hen there is penetration of the skull by an object that reaches brain tissue. Specific effects vary based on the severity of the injury, the location of the fcy(ies) (e.g., most commonly the frontal and temporal lobes), and pre-

1 morbid functioning (Harvey, 2002; Rotto, 1998). However, the majority of TBIs are considered mild (Yeates & Taylor, 2005). Younger children are more Idy to exhibit worse outcomes due to having fewer previously established cognitive skills at the time of injury (Gil, 2003).

I Effects of Traumatic Brain Injury

Determining neurocognitive effects from a TBI is difficult based on medical technology (e.g., CT scan, MRI). Neuropsychological assessments have been found to be the most sensitive to subtle changes with the most common difficulties found in novel learning, processing speed, and word finding or recall (dysnomia) (Miller & Donders, 2003). Diffuse effects tend to include difficulty concentrating, confusion, irritability, fatigue, and the need for increased effort to complete tasks. Memory skills are frequently initially depressed, although improvement during the first year following the injury may occur for individuals with mild-to-moderate TBI. Academic perform­ance may remain more stable, although math tends to be more at risk for negative change with some findings of mild decrements in reading compre­hension (Ewing-Cobbs & Bloom, 2004). Research suggests that negative effects are more noticeable as the student ages and becomes responsible for his or her own executive functioning (Gil, 2003; Savage, Pearson, McDonald, I Potoczny-Gray, & Marchese, 2001).

Psychiatric symptoms that may occur following a TBI include depressing

irritability, posttraumatic stress disorder (PTSD), aggression and difficult!

regulating behavior, and obsessive-compulsive symptoms (MassaglietalB

2004). Due to increased efforts required for mastery of cognitive tasks, mental

fatigue may lead to further reduced efficiency and increased frustratetion

(Tremont et al., 1999). Also, aspects of these symptoms may result in

children/adolescents with TBI having fewer friends than their classmate

(Prigatano & Gupta, 2006). Physical symptoms may include insomnia, арре

tite changes, headache, nausea, vestibular changes (e.g., altered sense of

balance), and fatigue (Rotto, 1998; Yeates & Taylor, 2005).

Project ACCESS documented a reduction in neurological symptoms ten

months following a TBI, while neurocognitive symptoms increased during that

time. Many were able to return to school by one month postinjury, while some

required several months' recovery prior to reentry (Hooper et al., 2004). It is

important to note, however, that 9 percent of students in this study ехрeri

enced new learning/behavioral problems one month following their injury

Even at four months, 15.2 percent experienced difficulties, while 10 percent

still exhibited deficits ten months later, including continued headaches, dill

culties with attention and learning, and impaired frustration tolerance (Hoopel

et al., 2004). Overall, symptoms have lasted for up to five years following]!

mild TBI with the most rapid recovery occurring six to twelve months fire

the injury date (Harvey, 2002).

School Reintegration Following Traumatic Brain Injury

Schools are increasingly providing primary intervention services as access!

to rehabilitation facilities/services wanes (Ewing-Cobbs & Bloom, 2004м

Further, TBI was added as a category within the special education service!

delivery system in 1990 (Gil, 2003). In 2006,1,027 children between the ages of

3 to 5 were being served under TBI, and 23,867 children between the ages of 6

to 21 were being served (Data Accountability Center, 2006). In order to

develop appropriate services, specific assessment of cognitive skills (e.g

short-term memory, attention) is required, as opposed to broad cognitive ■

assessment (intelligence) (Gil, 2003). The consideration of pain as a confound!

during assessment is also vital, as decreased performance may be caused by I

the injury, pain, or both (Nicholson, Martelli, & Zasler, 2001). It is recom

mended that neuropsychological assessment not occur during the acute!

recovery phase due to rapid changes in cognitive status, and an IEP or I

504 plan should be reevaluated every six to eight weeks as most appropriate!

to accommodate the student's gradual recovery (Thomas & Grimes, 2002).!

Annual reevaluation of deficit areas for the first three years postinjury will I

School Reentry for Children Recovering from Neurological Conditions 215

Itelp to capture areas of skill recovery and those areas with continuing

[difficulties (Ewing-Cobbs & Bloom, 2004). Other classroom-based indices of progress monitoring may also be useful.

■A designated school case manager may engage in early communication

nth the family/medical team in order to begin planning to support the child's needs (Ewing-Cobbs & Bloom, 2004). The school neuropsychologist is inagood position to fill this role due to knowledge regarding school systems/ sendees, consultation skills, and knowledge of empirically supported assess-

I ment/intervention techniques.

■A flexible schedule for the student to reenter school, such as part-time attendance, is recommended. General skills necessary for reentry include ability to sustain attention for 10 to 15 minutes, ability to complete 20 to 30 minutes of class work, ability to function within a group, ability to communicate needs, and ability to follow directions. Specific instructional approaches including direct instruction, which involves preteaching, modeling, shaping, reinforcement, and continuous assessment, and error­less learning have been found to lead to the successful learning in students

Eh ТЫ (Bigler, Clark, & Farmer, 1997; D'Amato & Rothlisberg, 1997;

Kemrud-Clikeman, 2001; Wilson, Baddeley, & Evans, 1994).

■Possible classroom accommodations/modifications include adding a rest period to the school day, implementing recognition versus recall tasks, increasing classroom structure, implementing organizational tools such as a daily planner, multimodal instruction, transitional programming for older

■dents (e.g., career education and training), increasing communication among settings, providing education for teachers/staff/students, offering counseling support (Harvey, 2002; Savage et al., 2001), and increasing com­munication between educators during the student's educational transition to assist with appropriate educational expectations. The student with TBI may be less likely to be perceived as "lazy" or "unmotivated" if teachers are appropriately informed about the effects of TBI and the specific child's learning profile (Ewing-Cobbs & Bloom, 2004). Related services may be Kcessary compliments in order to address sensory and/or psychosocial

Bis (Savage et al., 2001).

■Antecedent control techniques (e.g., prevention of problems) are most

: beneficial in managing behavior due to the inability of some individuals with TBI to effectively learn from consequences of their behavior (Savage & al., 2001; Ylvisaker et al., 1995). Possible suggestions include actively planning to avoid sensory overload (e.g., quiet classroom/work area), plan-

; ningfor transitions (Savage et al., 2001), allowing choices when possible, and

' establishing a routine (Harvey, 2002). Finally, intense protection from further injury is necessary, as subsequent TBI tends to have cumulative effects.