What are the key characteristics of interventions for children with early brain injury? - Chapter 12

The goal of treatment practices for children with brain disorders is to obtain the best possible outcome across cognitive, social, behavioural, and functional domains. To obtain this ultimate goal, the two primary aims of paediatric rehabilitation for children with brain injury are:

1. To reduce the daily consequences of impaired cognitive functioning.
2. To reduce the level of handicap, with the ultimate goal of community reintegration. 

In order to achieve these goals, the focus in the paediatric context comprises working with both the child and his or her family to identify an association between impairments and functional or everyday difficulties. Many interventions have been developed, although few are specifically designed for children with early brain insult, in particular interventions with a neuropsychological orientation are rare. Instead, the focus is more commonly on the paediatric domain in order to reintegrate the child back to home and back to school as soon as possible. In line with this, in this chapter, common models of intervention will be discussed in the context of school and home, both of which form major settings in children's life. In choosing an intervention it is best practice to, wherever possible, select an evidence-based intervention, meaning that this intervention has been tested thoroughly through high-quality trials. 

What are the two primary settings in which rehabilitation plays an important role? 

For children with brain injury, entry or reintegration into the school environment is commonly seen as a very important step in the recovery process. Initially, the aim is to enhance socialisation and adjustment, even if the child is not ready yet to benefit from the educational curriculum. Hence, the school becomes a de facto rehabilitation provider, in which often there is no previous expertise in working with children with neuropsychological deficits. Optimally, the school, family, and rehabilitation team collaborate via regular school meetings and less formal contact in order to provide an appropriate context and educational programme for the child. It is the role of the neuropsychologist to inform the child's teacher(s) about the neurobehavioural strengths and weaknesses and the way these may manifest themselves in the classroom or playground. The most critical task of the neuropsychologist is to communicate medical and assessment data to non-experts, such as teachers and family. A model for this has been proposed by Rourke and colleagues (1996), suggesting that relevant factors for consideration are:

1. The types of skills impaired.
2. The number of skills impaired.
3. The degree of impairment.
4. The capacity of the child for adaptation.
5. The quality of intact abilities.

These five factors should be integrated with the demands of the child's environment, both in the academic and social context. Furthermore, in order to design a realistic and feasible intervention program, these factors should be taken into account when formulating the treatment goals. 

The neuropsychologist may also contribute to the development and evaluation of specific educational or behavioural programmes, with the emphasis on:

1. The importance of understanding the demands of the child's environment.
2. Setting realistic and achievable therapy goals.
3. Providing the child, family, and school workers regular feedback on the progress.

Frequently, accessible supports are provided through community-based early intervention services. Typically, these focus on maximising development in speech and language and motor skills, with behaviour management where necessary. In addition, because many children with brain injury exhibit social and behavioural problems (such as impeded social development and social interaction, as well as social isolation), a range of interventions has been developed that may be helpful within the classroom and playground. Sometimes, it may also be beneficial to discuss the medical condition of the child with the class, for example when the child has epilepsy, in order to demystify any unusual aspects of the child's presentation. The child may be referred to a supportive group of peers or playground activities may be structured such that the child is able to join. These and similar elements can be integrated into comprehensive behavioural management programmes.

In addition to focus on school context, the scope of rehabilitation and intervention following early brain injury also needs to address family issues. Again, the neuropsychologist can contribute here by combining knowledge of the likely behavioural and social effects of brain injury with an understanding of normal development and adjustment responses and the role of the family in these domains. 

Which two perspectives on rehabilitation are there? 

Broadly speaking, neuropsychological interventions for children with either acquired or developmental brain disorders fall into one of two categories: substitution or restoration of function. Each of these perspectives attempts to minimise the consequences of neurobehavioural deficits and to maximise the opportunity to utilise the strengths of the child. 

Substitution of function is perhaps the most popular approach to neuropsychological rehabilitation. Here, the idea is to train and support the individual to perform various activities using alternative strategies or to modify the environment of the child, enabling the child to compensate for his or her cognitive deficits and hence decreasing the functional impact of the deficit. 

Restoration of function aim to restore the function. Methods focus on improving the individual's capacities, for example attention, by re-establishment of impaired functions. Restorative interventions are developed to treat the consequences of brain injury and acquire an initial evaluation to identify impaired abilities. Next, the child is trained using specific exercises or activities focusing on deficient cognitive abilities in an attempt to improve these abilities as well as to impact more generally on cognitive functions. Rather than focusing on the strengths of the child, here the focus is on the weaknesses of the child, and the goal of the intervention is to develop these skills (back) to normal levels via training. Next to methods that directly focus on the impaired ability, there is also an indirect approach. Such an indirect approach avoids the impaired skill and provides training for peripheral skills. The underlying assumption here is that the specific deficit of the child is due to a problem in a related skill area. For instance, in the context of learning disabilities, sensorimotor integration programmes are often used with the rationale being that an improvement in sensorimotor skills yields increased reading proficiency.