The following curriculum guide was designed to assist educators in developing appropriate educational goals for students who have sustained traumatic brain injuries (TBI) and other acquired brain injuries (ABI).

What is generally referred to as "cognition" is a complex collection of mental skills, including attention, memory, language skills, perception, 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, whether through trauma or due to stroke or tumor, typically suffer loss or alteration of one or more of these skills. This Cognitive Curriculum for Students with TBI/ABI provides a scope and sequence of these cognitive functions.

This curriculum would not be functional if not embedded within a more traditional scope and sequence of academic skills and content. Therefore, while moving through appropriate levels of an academic curriculum, goals and objectives of the Cognitive Curriculum for Students with TBI/ABI are employed to promote progress and should be individualized and measurable.

Several factors affect where a student fits within the scope and sequence of the Cognitive Curriculum for Students with TBI/ABI. 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 what these goals and objectives should be toward recoupment 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. Once an IEP is developed, more frequent review may be warranted, specifically early on in recovery.

Cognitive rehabilitation should follow two parallel paths. The first goal is for the recoupment of academic and functional skills lost due to the brain injury. Secondly, where deficits are found, the student should be taught compensatory strategies. The Cognitive Curriculum for Students with TBI/ABI provides the framework for the assessment, goal setting and treatment of cognitive impairments secondary to neurologic insult such as traumatic or other acquired brain injury.

Cueing

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 along with their definitions:

Physical

  • hand-over-hand: physical guidance given through the task.
  • tactile cueing: gentle touch to direct movement, behavior or cognition.

Visual

  • modeling: therapist or teacher demonstrates expected performance.
  • gesture: facial expression or bodily movement that conveys meaning.
  • pictorial: picture to elicit desired response.

Verbal Prompts

  • phonemic: first sound or rhyming word is given.
  • multiple choice
  • true/false
  • 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

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, the student’s 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.

Following a brain injury, there may be spontaneous recovery of cognitive functions such as attention. However, the teacher will need to recognize that if this is not the case, compensatory strategies will need to be put in place to help the student attend to the task at hand. The following list provides common attention sequelae following a TBI/ABI:

  • easily distracted
  • off task and can’t self-return to task
  • easily confused
  • difficulty starting a task
  • completes part of the task
  • difficulty with change in routine
  • makes off-topic comments
  • inconsistent performance
  • difficulty following a conversation/lecture
  • difficulty working independently

Attention: Suggested Areas to Consider

Suggested Areas to Consider:

The Student will maximize arousal/alertness given optimal positioning.

  • The student will respond to basic stimulation by doing ____ (e.g., opening eyes, making a noise, etc.) ___ % of time.
  • The student will show localized response to stimulation by doing ____ (e.g., turning toward or away from stimuli) ___% of time.
  • The student will attend to simple commands by completing them ____ % of the time.

The Student will maximize selective/focused attention by demonstrating the ability to selection something and focus on it and to attend to a restricted range of information.

  • The student will direct attention (visual or auditory) to a specific stimulus for ____ seconds _____ % of the time.
  • The student will demonstrate a response to stimulus (e.g., visual, auditory, tactile) ___ % of the time.

The Student will maximize sustained attention by attending for as long as necessary to complete task.

  • The student will participate in preferred task for ____ seconds/minutes with ____ cues for ____ % of the time.
  • The student will participate in nonverbal task for ____ seconds/minutes with ____ cues for ____% of the time.
  • The student will participate in verbal task for ____ seconds/minutes with ____ cues for ___ % of the time.

The Student will maximize the ability to shift attention by demonstrating the ability to change focus for attention with task demands.

  • The student will change activities in class when directed to do so within ___ seconds with ___ cues for ___% of the time.
  • The student will shift attention within desired activity within ____ seconds with ___ cues for % of the time.

The Student will maximize divided attention by demonstrating the ability to pay attention to two things at once.

  • The student will demonstrate the ability to write notes from dictation with ____ cues ____ % of the time.
  • The student will participate simultaneously in conversation while completing a functional task (e.g., eating, walking, dressing) with ____ cues ____ % of the time.

Memory

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, likewise interventions directed to any of these domains will also 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 in the brain, 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 (sensory, short-term, and long-term memory) 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/accommodation 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/executive functioning and/or memory deficits.

Memory and the Capacity to Learn New Information

Student will maximize orientation skills (e.g., to person, place, and time)

  • Student will correctly state full name with _____ cues _____% of time.
  • Student will correctly state age-appropriate autobiographical facts, such as age, birthday and grade in school, with _____ cues _____% of time.
  • Student will correctly state current locations with _____ cues _____% of time.
  • Student will correctly state time (including hour, day, date, month, season and year, as age-appropriate) with _____ cues _____% of time.

Student will maximize learning new information

  • The student will spontaneously use rehearsal in a classroom or therapy activity ___ % of the time when learning new information with ___ prompts.
  • The student will describe and demonstrate the use of rehearsal upon request with ___ prompts.

Student will maximize memory organizational strategies.

  • Student will use “chunking” of related items ___ % of time.
  • Student will demonstrate use of graphic organizers supplied by instructor with ___ % accuracy.
  • Student will use visual imagery as a memory-enhancing strategy with ___ cues ___ % of time.
  • Student will use organization strategies such as PRQST for remembering extended passages with ___ prompts.
  • Student will relate newly-presented information to previously-learned information as a memory device with ___ cues ___ % of time.

Student will increase self-awareness of memory performance and problems

  • The student will predict own memory performance prior to task and will evaluate accuracy of prediction following completion with ___ prompts.

Student will maximize recall of newly learned information

  • The student 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. with ___ prompts.
  • The student will use self-cueing devices such as context, phonemic, visual, etc. with ____ prompts.
  • The student will request cues from others when attempting to retrieve information from LTM with ___ prompts.

Language

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 brain injury is to maximize the child's ability to communicate, rather than to teach a particular skill or structure. Therefore, phonological goals should focus on using strategies to increase intelligibility of connected speech (e.g., decreasing rate, using augmentative/alternative communication). Syntax goals should be directed toward improving reading and written language... Errors that are most disruptive to successful communication typically occur in the semantic and pragmatic components of language. Goals in these areas should address skills such as efficient word retrieval, categorizing, direction following and sequencing of language.

Language: Suggested Areas to Consider

The student will maximize phonological skills language skills.

  • The student will use strategies to increase intelligibility of connected speech (decrease rate, for example) ___ % of the time with __ cues

    The student will use augmentative communication device (low tech or high tech) to interact with the environment for (#) of functions per activity (request clarification, request and item, ask a question, make a greeting, for example) with __ prompts

The student will maximize semantic language skills.

  • The student will identify pictures _____% of the time with _____ cues.
  • The student will use appropriate word retrieval strategies _____% of the time with _____ cues.
  • The student will demonstrate understanding of multiple meaning words _____% 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 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 follow _____ step commands with _____ cues/repetitions _____% of the time
  • The student will demonstrate understanding of abstract language _____% of the time with _____ cues.

The student will maximize syntactic language skills.

  • The student will combine noun-verb sequences to compose simple sentences orally
  • The student will formulate a 3-5 word sentence using appropriate sentence structure ______% of the time with ______ cues.

The student will maximize 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 and 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 and classroom routines _____% of the time with ______ cues.

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.

Student will maximize basic visual sensory functioning

  • Student will comply with necessary accommodations (e.g., patch, glasses) for _____ amount of time with ____ prompts.

Student will maximize exploration and identification of objects in 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.

Student will maximize 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 incomplete or ungraded _____% of the time with _____ cues.

Student will maximize 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 maximize visual/constructional ability

  • Student will demonstrate the ability to draw a specified figure without a model ______% 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 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.

Executive Functions

Executive function (EF) does not refer to one particular skill, rather, it is an umbrella term that includes a collection of interrelated functions. These functions are responsible for purposeful, goal-directed, problem-solving behavior. Executive function relates to the highest level of cognition. Such behaviors include judgment, awareness and making decisions. In order to manage executive functions, a student will need to initiate behavior, inhibit other behaviors, select relevant task goals, plan and organize, problem-solve, be flexible and monitor their own behavior. From a neuro-anatomical standpoint, executive functioning skills are primarily mediated in the frontal cortex of the brain, though there is communication with other parts of the brain, including those that control spatial, visual and verbal skills. While the frontal lobe does not typically mature until late adolescence or young adulthood, there are aspects of executive functions that are typically required of students throughout most of the school day. Therefore, deficits in this area, can negatively impact school performance. The frontal lobe is particularly vulnerable in a traumatic brain injury and deficits in this area are frequently observed following a TBI.

There are many accommodations that may be needed to assist the student with EF deficits. However, we also want the student to learn to master using the accommodations. There are some areas of executive function that are best supported through accommodations rather than specific goals. Therefore, specific IEP goals should address the student’s difficulty in EF. The goals listed below will hopefully help you conceptualize how this area may negatively impact school performance and how IEP goals can help target this area of function.

Executive Functioning Skills: Suggested Areas to Consider

The student will maximize organizational skills (e.g. supplies, school work, homework, locker)

  • When given a specific graphic organizer, explained the task verbally and visually and provided with information to put on the organizer, the student will complete the task with no more than cues % of the time.
  • When given an advance organizer (e.g., agenda book, phone app), the student will record homework including name of class, description of assignment and date due with ____ cues ____ % of the time.
  • When given a homework folder, the student will place the homework in the folder with ____ cues and will turn in the homework with ____ cues ____ % of the time.
  • Given a checklist, the student will maintain an organizer locker by placing lunch on top shelf, notebooks in middle shelf and textbooks on bottom shelf with ____ cues ____ % of the time.
  • Using learned strategies (e.g., graphic organizer, rubric, underline, highlight) and fading adult support (direct, cues), the student will prepare an organized outline before proceeding with writing assignment ____ % of the time.

The student will maximize initiation skills.

  • Given ____ verbal cues, the student will begin the task within ____ seconds ____ % of the time.
  • Given ____ nonverbal cues (e.g., visual on desk, alert on phone), the student will begin the task within ____ seconds ____ % of the time.

The student will maximize problem-solving skills.

  • When given a list of items to complete, the student will correctly prioritize assignments what asked what task should be completed first and why, given ____ cues ___% of the time.
  • When given role playing scenarios, the student will correct identify the correct response given ____ cues ____ % of the time.
  • The student will complete ____ grid deductive reasoning puzzles with ____ cues ____ % of the time.
  • When given a multi-step assignment, the student will complete a Goal-Plan-Do-Review sheet. The assignment should be broken down into specific objectives such as having the student first identify the goal when given key questions such as What do you want to accomplish? What do you want to achieve? They should identify a possible obstacle in achieving the goal and how to resolve the issue given ____ cues ____ % of the time.
  • The student will identify two alternatives to a given social problem with ____ cues ____ % of the time.