The following curriculum guide was designed to assist educators in developing appropriate educational goals for students who have sustained traumatic brain injuries (TBI).
What is generally referred to as "cognition" is a complex collection of mental skills, including attention, perception, memory, language skills and executive functions. These mental attributes allow each of us to make sense of our surroundings and function within them. Students who have sustained brain injury typically suffer loss or alteration of one or more of these skills. This Cognitive Curriculum for Students with TBI provides a scope and sequence of cognitive functions.
This curriculum would not be functional if not embedded within a more traditional scope and sequence of academic skills or content. Therefore, while moving through appropriate levels of an academic curriculum, goals and objectives of the Cognitive Curriculum for Students with TBI are employed to promote progress.
Several factors affect where a student fits within the scope and sequence of the Cognitive Curriculum for Students with TBI. The first consideration is developmental. That is, students' goals and objectives will be based on normal cognitive growth and development within each domain. Other considerations are pre-injury functioning in intellectual, academic and adaptive domains. When data is available as to the student's pre-injury functioning, this information may support not only a particular placement within the Cognitive Curriculum scope and sequence, but also guide goals and objectives toward either recoupement or compensatory training. The third factor to be considered is the brain injury itself. Injury severity (whether it was focal or diffuse), the primary areas of the brain affected and the resultant cognitive deficits guide the experienced therapists and teachers as to what parts of the scope and sequence will be appropriate.
Cognitive rehabilitation should follow two parallel paths. The first goal is for the recoupement of academic and functional skills lost due to the traumatic brain injury. Secondly, where deficits are found, the student should be taught compensatory strategies. The Cognitive Curriculum for Students with TBI provides the framework for the assessment, goal setting and treatment of cognitive impairments secondary to neurologic insult such as traumatic brain injury.
Throughout this curriculum guide, goals and objectives will make reference to various types of cues. The following is a guide to the types of cues referred to in the Cognitive Curriculum for Students with TBI, along with their definitions.
- hand-over-hand: physical guidance given through the task.
- tactile cueing: gentle touch to direct movement, behavior or cognition.
- modeling: therapist or teacher demonstrates expected performance.
- gesture: facial expression or bodily movement that conveys meaning.
- pictorial: picture to elicit desired response.
- phonemic: first sound or rhyming word is given.
- multiple choice
- probing questions: asking "wh" questions.
- concrete: explicit directions.
- abstract directions: directions requiring an inference.
- verbal modeling: therapist or teacher demonstrates expected verbal response.
- semantic: contextual, associative, defining information given.
Attention has always been a central concern to teachers. The brain's ability to focus and maintain attention on objects and events is crucial to learning. Attention is basic to classroom motivation and management. At the most basic level, a child must first be awake and alert. Once ready for attending, an effective attentional system must be able to (1) identify and focus on the most important items in the environment, (2) sustain attention on its focus while monitoring related information and ignoring other stimuli, (3) shift attention when new information warrants that shift and (4) attend to more than one stimuli simultaneously.
- Student will respond to basic stimulation with optimal positioning with eyes open.
- Student will show localized response to stimulation.
- Student will follow simple commands.
Goal: Selectivity/focused - possess the ability to select something and focus on it; attend to a restricted range of information
- Student will direct attention (visual or auditory) to a specific stimulus.
- Student will demonstrate response to stimulus.
Goal: Sustained attention - attend for as long as necessary to complete task appropriately
- Student will participate in preferred task for ______ minutes with _____ re-directions.
- Student will participate in non-verbal task for _____ minutes with _____ re-directions.
- Student will participate in verbal task for _____ minutes with _____ re-directions.
- Student will participate in written task for _____ minutes with _____ re-directions.
Goal: Shift attention - ability to change focus for attention with task demands
- Student will change class sessions.
- Student will change activities within a session.
- Student will shift attention within desired activity.
Goal: Divided attention - ability to pay attention to two things at once
- Student will demonstrate the ability to write notes from dictation.
- Student will participate simultaneously in conversation while eating, walking, dressing, appropriately.
Memory is essential to all cognitive activity. Most learning -- particularly academic learning -- is a process of improvement in memory over repeated presentation of information. Deficits in memory have been identified as among the most common sequelae of neurological insult. In the classroom and other naturalistic settings, however, it is difficult to isolate deficits in memory from problems in other related cognitive domains, such as perception, language and attention. Impairments in any of these areas can impact memory, while interventions directed to any of these domains will have beneficial effects on memory function. In addition, different categories of experience (e.g., a motor pattern, a fact, a personal experience) are processed through different memory systems, any of which may be disrupted depending upon the nature and location of injury. Thus, the presentation, as well as the rehabilitation, of memory impairment must take diverse forms. For the purposes of curriculum development, however, it is useful to conceptualize all types of memory as occurring over three sequential stages which differ in terms of cognitive processes involved, duration, capacity and format for encoding. Two of these stages -- short-term memory and long-term memory -- are available to rehabilitation efforts and are discussed below.
Short-term memory (STM) refers to the stage of information processing immediately following sensory registration, during which recognition, organization, filtering and coding of information occur prior to transfer to long-term memory. Capacity of short-term memory is limited and increases with age to seven, plus one to two items in adults. Information in STM is probably maintained throughout transient electrical or chemical changes in brain cell activity. Duration is brief (less than 30 seconds), but contents of STM can be renewed indefinitely with active rehearsal. When STM is applied (i.e., information is actively manipulated, elaborated, combined, etc.) for problem- solving, it is referred to as working memory. Impairment of STM is frequently seen following TBI, and may reflect attentional and/or memory deficits.
Memory and the Capacity to Learn New Information
Goal: Orientation to Person -- Become oriented to person (i.e., regain access to stored information regarding identity and sense of self)
- Child will correctly state full name with _____ cues _____% of time.
- Child will correctly state age-appropriate autobiographical facts, such as age, birthday and grade in school, with _____ cues _____% of time.
Goal: Orientation to place - spatial context and Become oriented to place
- Child will correctly state current locations with _____ cues _____% of time.
Goal: Orientation to time -- temporal context.
- Child will correctly state time (including hour, day, date, month, season and year, as age-appropriate) with _____ cues _____% of time.
Goal: Increase duration of STM trace by rehearsal
- The student will describe and demonstrate the use of rehearsal upon request.
- The student will spontaneously use rehearsal in a classroom or therapy activity.
Goal: Become a “strategic learner” by applying organizing strategies
- The student will increase functional capacity of STM by use of "chunking" of related items.
- The student will demonstrate use of graphic organizers supplied by instructor.
- The student will describe the technique of visual imagery as a memory-enhancing strategy.
- The student will describe and demonstrate use of organizing strategies such as PQRST for remembering extended passages.
- The student will relate newly-presented information to previously-learned information as a memory device.
Goal: Become aware of own memory performance and problems
- The student will predict own memory performance prior to task and will evaluate accuracy of prediction following completion.
Goal: Fill in "gaps" in LTM identified by evaluation
- Child will review previously-learned academic information and will demonstrate mastery at or near pre-injury levels.
Goal: Use external memory devices
- The student will be trained in and will spontaneously make use of external prompts for retrieval from LTM, such as a memory book with daily schedule and critical information, lists, calculator, tape recorder, graphic organizers, etc.
Goal: Use self-generated memory devices
- The student will use self-cueing devices such as context, phonemic, visual, etc.
- The student will request cues from others when attempting to retrieve information from LTM.
In the oral/aural modality, language can be defined as, "a code whereby ideas about the world are expressed through a conventional system of arbitrary signals for communication" (Lahey, 1988). Language includes a receptive component (comprehension of language) and an expressive component (using language to communicate). For ease of discussion, language is traditionally divided into four components:
- Phonology: The speech sounds of a language system
- Semantics: The meaning system of a language
- Syntax: Sequencing units of meaning to form utterances
- Pragmatics: Adapting language to communication contexts
The overall goal of speech and language therapy immediately following traumatic brain injury (TBI) is to maximize the child's ability to communicate, rather than to teach a particular skill or structure. Therefore, phonological goals focus on using strategies to increase intelligibility of connected speech (e.g., decreasing rate, using augmentative/alternative communication), or are directed toward reading and written language. Errors that are most disruptive to successful communication typically occur in the semantic and pragmatic components of language.
Scope and Sequence: Language Goals and Objectives
I. The student will maximize his semantic language skills.
- The student will follow _____ step commands with _____ cues/repetitions _____% of the time.
- The student will identify pictures _____% of the time with _____ cues.
- The student will demonstrate receptive language vocabulary for _____ (e.g., class thematic unit, Alphatalker vocabulary, developmental age vocabulary) through the modality of _____% of the time with _____ cues.
- The student will demonstrate understanding of multiple meaning words _____% of the time with _____ cues.
- The student will demonstrate understanding of abstract language _____% of the time with _____ cues.
- The student will request objects and actions through the modality of speaking, gestures, sign language and/or an augmentative communication device _____% of the time with _____ cues.
- The student will name items in a category _____% of the time with _____ cues.
- The student will name a category when provided with items from that category _____% of the time with _____ cues.
- The student will use appropriate word retrieval strategies _____% of the time with _____ cues.
II. The student will maximize his pragmatic language skills.
- The student will comment to express intent through the modality of speaking, gestures, sign language and/or an augmentative communication device _____% of the time with _____ cues.
- The student will ask questions through the modality of speaking, sign language, gestures and/or an augmentative communication device _____% of the time with _____ cues.
- The student will increase his ability to communicate non-verbally through use of appropriate vocal inflection, facial expression, eye gaze and/or gestures _____% of the time with _____ cues.
- The student will increase his ability to communicate in context by exhibiting appropriate topic maintenance and initiation, response during conversation and awareness of social context _____% of the time with _____ cues.
- The student will demonstrate appropriate message repair by recognizing communication breakdown, considering his listener's needs and using clarification strategies _____% of the time with _____ cues.
- The student will increase his ability to demonstrate cohesiveness of narration by sequencing information ____% of the time with _____ cues.
- The student will participate in classroom routines _____% of the time with ______ cues.
III. The student will maximize his syntactic language skills.
- The student will formulate a sentence using ______ sentence structure ______% of the time with ______ cues.
IV. The student will maximize his phonological skills.
- The student will use strategies to increase intelligibility of connected speech (e.g., decrease rate, use augmentative communication) _____% of the time with ______ cues.
Lahey, M. (1998). Language disorders and language development. New York: MacMillan Publishing Company. pg. 2.
Visual Perceptual/Spatial Constructional
Sensory deficits are attributed to impaired vision related to a defect anywhere between the eye to the optic nerve to the primary visual cortex. Perceptual deficits, on the other hand, are attributed to deficits from the primary visual cortex, secondary visual cortex or the tertiary multimodal association cortex. Although it may be difficult to separate sensory from perceptual/spatial defects in some severely brain damaged patients, deficits in perception are often observed despite intact sensory ability. When a question of deficits in sensory and/or perceptual ability arise, a thorough ophthalmology evaluation should be requested and attempts made to correct sensory deficits as much as possible. The following objectives and goals were designed to address perceptual skills, such as making sense of and constructing visual information rather than sensory deficits.
Following brain damage, defects in identification of the formal characteristics of objects (visual perception) and defects in the localization of objects in space (visual spatial skill) have been observed. Patients with brain damage often show defective performance on one task and not the other. Neuroanatomically, there are two cortical visual association systems thought to be involved in this dichotomy. The inferior occipitotemporal system subserves object recognition and the occipitoparietal system subserves appreciation of spatial relations.
Visuoconstructional ability involves the ability to create an object through drawing or building from a model, picture, or visual image. This ability is partially dependent on visuoperceptual and spatial skills, as well as other factors such as fine motor skill and planning.
Goal: Maximize basic visual sensory functioning
- Student will comply with necessary accommodations (e.g., patch, glasses) for _____ amount of time with ____ prompts.
Goal: Explore and identify objects in all areas of space (levels-startle, verbal cue, spontaneously)
- Student will scan from left to right in order to find target in _____ area (e.g., tray, room) _____% of the time with _____ cues.
- Student will identify targets in all areas of space to find target in ______ area ______% of the time with ______ cues.
Goal: Recognition of visual stimuli
- Student will identify three-dimensional objects _____% of the time with _____ cues.
- Student will identify photographs _____% of the time with _____ cues.
- Student will identify line drawings _____% of the time with _____ cues.
- Student will perform visual closure by recognizing objects presented partially incompleted or degraded _____% of the time with _____ cues.
Goal: Visual spatial organization
- Student will use visual cues to successfully navigate in _______ environment with _____ cues.
- Student will discriminate features (i.e., size, angles, orientation) and assign meaning to visual stimuli (e.g., graphs, mental puzzles) _______ of the time with ______cues.
- Student will demonstrate the ability to copy a specified figure _____% of the time with _____ cues.
- Student will demonstrate the ability to draw a specified figure without a model ______% of the time with _____ cues.
- Student will demonstrate the ability to replicate a three-dimensional design _____% of the time with _____ cues.
- Student will demonstrate the ability to build a specified three-dimensional design without a model _____% of the time with _____ cues.