Indicated Interventions 455potential it presents for long-term dif“culties into adulthood.
As with other injuries and illnesses that occur in childhood,
TBI disrupts the normal course of development. Tasks previ-
ously mastered must be relearned before the child can move
forward (Sherwin & O•Shanick, 1998). The manner in which
this disruption occurs varies as a function of pre- and postin-
jury factors, including the child•s age, premorbid ability,
achievement and personality, the nature and severity of the
injury, and the quality of early medical intervention, ongoing
rehabilitation and educational services, and family, friends,
and community resources (Ylvisaker, 1998). These factors
combine in many different ways, resulting in a broad range of
clinical presentations.
Despite the varying clinical pictures of children with TBI,
researchers have attempted to identify common neurocogni-
tive characteristics among these children. Visuomotor and vi-
suospatial functions have been consistently described as
areas of weakness (e.g., Chadwick, Rutter, Shaffer, & Shrout,
1981; Winogron, Knights, & Bawden, 1984). Decreased
arousal and alertness are common in the early phase of recov-
ery, and dif“culties with attention (e.g., distractibility, poor
attentional control, dif“culty shifting attention) may persist
(Dennis, Wilkinson, Koski, & Humphreys, 1995). Problems
with encoding and retrieving new information are also com-
monly observed (Levin, Ewing-Cobbs, & Eisenberg, 1995).
Executive functions (i.e., organizing, self-monitoring, rea-
soning, and judgment) are often signi“cantly impaired, re-
sulting in social, behavioral, and affect-regulation dif“culties
as well as academic struggles. Children with TBI often expe-
rience dif“culties in everyday activities that require them to
apply and/or generalize previously learned information in a
new way, retain information over time, and focus or monitor
attentional effort over time (Ewing-Cobbs, Levin, & Fletcher,
1998). These weaknesses may not readily be apparent with-
out observation of behaviors and cognitive functioning
within the naturalistic context of the child•s classroom. This
type of collaborative, multidisciplinary assessment is essen-
tial to highlight the impact of the child•s injury on daily func-
tioning and plan for an effective rehabilitation program
(Ylvisaker, 1998).
In most clinical settings, rehabilitation programs for severe
TBI in children involve a multidisciplinary team of profes-
sionals (physicians, nurses, occupational therapists, psycholo-
gists, speech and language psychologists, social workers, and
teachers), each working to enhance functioning. Empirical
studies examining the effectiveness of rehabilitation with this
population are sparse. In general, the literature consists mostly
of descriptive case studies that are not designed to evaluate
ef“cacy. Published studies lack control groups of children
matched on injury variables and preinjury demographic
variables, and children have not been randomized to receive
the intervention (Michaud, 1995). Additionally, many rehabil-
itative approaches are borrowed from adult models and
applied to children, with little attention to the vast differences
between children and adults in brain development, cognitive
processes, and the role of the family in recovery (Ylvisaker &
Szekeres, 1998). Early rehabilitation programs focused on im-
proving discrete cognitive processes via hierarchically graded
retraining exercises or by promoting compensation for spe-
ci“c cognitive weaknesses by teaching speci“c strategies in an
of“ce-bound setting. While techniques such as these often re-
sult in performance gains on rehabilitation-speci“c tasks, they
seldom transfer to functional activities in the child•s life (e.g.,
Frazen, Roberts, Schmits, Verduyn, & Manshdi, 1996), and
the extent to which these gains are maintained over time is un-
clear. This has led to a call for greater inclusion of functional
tasks into rehabilitation programs to bridge the gap between
skills being taught and •real-life functioningŽ (Gordon &
Hibbard, 1992, p. 364).
More recently, Ylvisaker (1998) proposed a framework
for cognitive rehabilitation, which emphasizes an integrated,
nonhierarchical, contextual approach that promotes enhanced
cognition as well as improved performance of functional ac-
tivities. Unlike traditional adult models, this framework
stresses the importance of collaboration with •everyday peo-
pleŽ (e.g., teachers, family members) as key members of the
child•s rehabilitation team (Ylvisaker & Feeney, 1998, p. 9).
This model acknowledges the competence of family mem-
bers, teachers, and others who have contact with the child
daily, and looks to them to provide valuable insights into the
child•s strengths, weaknesses, and motivation. Rehabilitation
efforts are focused toward meaningful, pragmatic aspects of
the child•s functioning such as enhancing school perfor-
mance (by improving planning, organization, and memory
functioning), prevention behavior problems (via contingency
management), and decreasing social isolation (by increasing
social contacts and improving social relations). Ylvisaker
argues that provision of rehabilitation services in multiple
settings encourages generalization and promotes mainte-
nance of gains. Embedding training in functional tasks from
the outset, rather than beginning with retraining exercises
that have less application to real-world settings, is also pre-
sumed to facilitate generalization. Involving and training
nonprofessionals in the rehabilitation program is particularly
important with managed care health insurance, which has
often reduced the intensity and duration of services provided.
Finally, in planning a comprehensive intervention pro-
gram for children with TBI, it is important to remember that
the child•s social ecology is impacted (Waaland, 1998). Chil-
dren may be painfully aware that school and learning are now