VIRGINIA COMMONWEALTH UNIVERSITY

NATIONAL RESOURCE CENTER
FOR TRAUMATIC BRAIN INJURY

Neuropsychology and Rehabilitation Psychology Division Department of Physical Medicine and Rehabilitation.

Pediatrics

QUESTION:
My child sustained a brain injury as a pre-schooler. Now she is in elementary school and does not seem to focus on the tasks at hand. The teacher says my daughter does not complete assignments and that she is very easily distracted by the other children and activities going on in the classroom. Even at home, I cannot get my child to stay focused on her homework; she wants to talk, play, and bounce from activity to activity. I have tried stricter and stricter discipline but she does not seem willing to do what I ask. Why isn’t this working? What types of disciplinary actions should I take to get her to behave and finish her school work?

ANSWER

You don’t mention how your child is feeling about her school performance, but I would expect that you are not the only one who is frustrated. Rather than focusing on disciplinary strategies first, I would recommend that you work with the school and other professionals to figure out why your daughter is having so much difficulty focusing on and completing tasks. Problems paying attention are often an effect of a brain injury and your daughter may be doing her best. My first suggestion would be to review any neuropsychological evaluations on your child to see if they noted impairments in attention and self monitoring skills. If your child has not undergone neuropsychological testing, you can find competent pediatric neuropsychologists in your area by contacting the Brain Injury Association.. Results of this evaluation will tell you not only what difficulties your child is having, but also what strategies facilitate her overcoming these difficulties.

Generally speaking, a behavioral change program that focuses on increasing desirable behaviors (e.g., staying on task) is likely to be most effective with your daughter. Your child’s teacher can help by changing the classroom environment to make it easier to pay attention: for example, by having your daughter sit at the front of the class close to the teacher, shortening tasks so that she is able to complete one short assignment before going on to another, and by placing her next to students who will model good on-task behaviors. Similar accommodations can be made for homework, such as providing a non-distracting environment and occasional breaks. You also may want to reward your daughter, with praise, stickers, or other positive feedback, each time she completes an assignment. If your daughter is old enough to set some of her own goals, she may be more motivated by a behavioral program that includes her personal goals and rewards. For example, she may set a goal of finishing her homework by 4:30 so that she can go out and play before supper. Her involvement in setting goals will help her to feel more in control and is also a good way for her to learn to monitor her own behavior.


QUESTION:
I have a baby that sustained a serious brain injury. I was told that some of the more subtle learning problems may not show up until my child goes to school and is required to master new tasks. What kinds of problems should I be looking for when he goes to school?

ANSWER #1:

For infants and preschool-age children with severe brain injuries, it is important to continue to provide special services, such as speech and language therapy, physical and occupational therapy, and special education. In particular, children who injure their frontal lobes may later develop behavior problems (a behavioral psychologist can help). Children with impaired communication development may have difficulty learning in school and relating to peers (a speech and language pathologist can help). Also, many younger children with brain injuries later experience problems paying attention or trying to remember (a special educator or cognitive therapist can help).

It is also important to have the child followed by a developmental pediatrician. Children need to be carefully monitored as they continue to develop and mature. The five peak maturation mileposts to monitor are:

ages 1 - 6
ages 7 - 10
ages 11 - 13
ages 14 - 17
ages 18 - 21.

Infants and preschool-age children with brain inures are still growing and their brains are still maturing. Providing services early and continuously can help the child through these developmental milestones.

ANSWER #2:

Children injured at a young age often have problems with sustained attention and concentration, language development, and motor skills. When your child first enters school, you may notice that he seems "immature" compared to others in his class. That is, he may show problems in some of the following areas: sitting still, listening to the teacher, understanding directions, learning new ideas, finishing his work on time, or talking about what he knows. He may have more trouble than other children learning to read, write, and solve math problems. You and his teacher may feel frustrated by the fact that he seems to learn things but then cannot remember them later or apply what he has learned in a slightly different situation. Your child’s uneven performance may make you wonder if he is just not trying hard enough. He may actually be working very hard to keep up. Because of his processing problems, he may become easily frustrated, overly fatigued, and irritable or clingy. Some children who have been injured may also have trouble getting along with others or making friends at school.

If you notice any of these problems or if your child’s teacher expresses concern, it will be important to talk with the teacher about your child’s history of brain injury. Educators may wish to conduct an evaluation of your child’s strengths and concerns. They may consult with a child neuropsychologist who specializes in evaluating children with brain injuries. The goal of such an assessment should be to identify ways to support your child’s success at school.


QUESTION:
I have a child who sustained a brain injury and is currently hospitalized. Some of the medical professionals have suggested that a child can have a better prognosis for recovery than an adult due to the resiliency of youth. Still others have said that just as each individual is unique, each injury is unique. Should I be optimistic about my child’s recovery due to her young age, or is it unrealistic to hang my hopes on this factor alone?

ANSWER
At this stage in your child’s recovery, it is essential to continue to hope for a positive outcome. However, young age alone is not a protective factor against future problems. Researchers used to think that the brain was more "plastic" at younger ages and able to compensate for injury during the course of development. More recent investigations indicate that younger children who sustain moderate to severe injuries are more likely than older youth to display impaired language and memory functioning; inattention and hyperactivity; slower recovery of motor, visual-spatial, and somatosensory skills; and decreased novel problem solving. Some evidence suggests that disruption of basic skills in the early years of development (e.g., language, memory, or motor skills) interferes with later developing, higher order skills (e.g., reasoning, problem solving). Even children who seem fully recovered from injury may experience "late cognitive effects," or the appearance of academic problems and declining skills over time. Such apparent declines in functioning may be due to delayed recognition of cognitive problems or to increasing performance demands as the child grows older.

The studies that have been conducted cannot predict your child’s specific outcome. The main thing to remember is that your child may be at risk for learning problems, particularly if the injury was moderate to severe. If you have concerns about his or her development at any point in time, seek help from rehabilitation or school professionals who are familiar with brain injury during childhood.

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