Ashton 2015
Ashton 2015
Ashton 2015
Educational Neuropsychology
Rebecca Ashton
Most children are in education for a large proportion of their waking life,
whether in school, nursery, college or some other educational setting.
Schools can make a difference to children’s academic outcomes, as well as
their well-being (Sellstrom and Bremberg, 2006), and what happens at school
can therefore influence the child’s development following a brain injury.
However, educators can only help with a child’s rehabilitation if they
know about the brain injury and if they know how to help. Too often,
teachers are unaware that the child has had a brain injury, especially if
the child has changed school or changed class since returning to school
(Hawley et al., 2004). Understanding of brain injury among educators is
also a concern (e.g. Linden et al., 2013), so school staff may need a range of
support if they are to be an effective part of the child’s rehabilitation plan.
Clinical neuropsychologists are well placed to help children with
brain injuries in many ways, but may find it difficult to provide the
support that schools need. Even if the systems in which they work
enable clinical neuropsychologists to be in contact with schools, the
gap between clinical and educational worlds can present a barrier to
effective partnership working.
Ernst et al. (2008) published an article on what clinical neuro-
psychologists in the USA need to know when working with educa-
tion colleagues. They made an informal analysis of the problems that
educational colleagues raised when trying to work with clinical neuro-
psychologists, summarised as follows (p. 965):
237
238 Neuropsychological Rehabilitation of Childhood Brain Injury
Application
Clinical and educational psychology usually form separate training
routes. Clinical psychology is invariably accepted as a basis from which
to move into specialist training in neuropsychology, but educational
psychology only in some countries (such as the UK). In some places,
including Australia and some US states, it is possible to train directly in
neuropsychology, although the curriculum is often clinical rather than
educational in nature. For example, the Australian Psychological Society
(2013) describes neuropsychology professional training using language
including, ‘patients’, ‘diagnosis’ and ‘treatment’.
Educational Neuropsychology 239
Adding layers of knowledge about how brain injury can impact upon
child development, learning, behaviour and relationships enables the
240 Neuropsychological Rehabilitation of Childhood Brain Injury
These areas are illustrated in the case study within this chapter.
Educational: Clinical:
Common ground:
Therapeutic
Knowledge and Knowledge of neuropsychology skills and
experience of Quickly establishing helpful knowledge
educational systems relationships
Understanding of Reflection and analysis Experience
pedagogical working acorss
approaches Formulation/hypothesising the age range
Linking assessment, theory,
Community research evidence and Individual/family
orientation intervention orientation
Assessment
An educational neuropsychology assessment may include psychometric
testing of cognitive functions (see Table 12.1). The focus, however, is
likely to be more functional, including academic progress and response
to interventions. Data from the educational setting are likely to be
integrated into the assessment, as well as information from the child
and family.
The purpose of the educational neuropsychology assessment is
to inform educational practice, which may include advice on the
most appropriate type of institution, groupings, curriculum, teaching
Background
• Injury and brief history
• Presenting concerns (may be different concerns from different people involved)
Educational history
• Did the child attend nursery/preschool?
• Which schools have they attended?
• Attendance record—before and since the injury?
• Any identified special educational needs before and since the injury?
• History of additional educational support provided
Educational assessments
• Academic assessments, ideally over time so that a trajectory can be
described pre- and postinjury
• Assessments of social, emotional and behavioural skills may already be
available, or the school can be asked to complete questionnaires such as the
strengths and difficulties questionnaire (Goodman, 1997)
• Other professionals’ assessments, e.g. psychologist attached to the school,
advisory teacher
Current provision
Look at the individual education plan:
• Do the targets address what the child needs to learn next?
• Are the targets clear and specific enough?
• Do the strategies/provision give the child a fighting chance of achieving
the targets?
• Are the staff monitoring and evaluating effectively (how will they know if the
target has been achieved)?
• Does the plan take into account advice from other professionals and from
parents?
• Provision map, showing what additional support is scheduled for the child
across the week
• Responses to interventions so far
(continued)
242 Neuropsychological Rehabilitation of Childhood Brain Injury
Neuropsychological assessment
Observations—in lessons and at break times. It is often worth trying to schedule
a visit when you can see a range of situations, e.g. different types of lesson,
smaller group work or one-to-one, directed and free-choice time. Can provide
lots of information about:
Self- and adult reports of physical health, including sleep, nutrition and
exercise
Cognitive and academic attainment tests—depending on what has already been
tested and what hypotheses have been generated
Self-assessment of abilities and relationships
Sociometry if appropriate—to gauge the child’s social standing within the class
or group
Intervention
Few approaches to intervention are supported by evidence from
research directly with children who have brain injuries, and those few
are denoted by asterisks in Table 12.2 and discussed in the next section.
In most cases, educational neuropsychology interventions are likely to
243
Academic skills
* Approach validated with at least one study including children with brain injuries.
244 Neuropsychological Rehabilitation of Childhood Brain Injury
Evidence Base
Background
Michael’s brain injury occurred perinatally, with hypoxic ischaemic
insult leading to neonatal encephalopathy. Michael experienced epilep-
tic seizures soon after birth, and longer-term cerebral atrophy. His injury
was generalised but more marked in left frontal areas of the brain.
This brain injury left Michael with quadriplegic cerebral palsy.
Consistent with the injury, motor skills on the right side of his body
were weaker than on the left side. In addition, Michael showed sig-
nificant general learning difficulties and language delay. Emotionally,
Michael was described by his parents as frequently anxious, and he
would become particularly distressed by changes to his usual rou-
tine. Shortly before the educational neuropsychologist’s involvement,
Michael had been given a diagnosis of autistic spectrum disorder.
At home, Michael’s family received support from the social services
disability children’s team. This support included direct funding for the
family to employ personal care assistance, as well as a social worker to
coordinate and review the care plan. The family also participated in the
ongoing medico-legal assessment process towards bringing a medical
negligence case against the hospital trust.
Michael accessed conductive education from the age of 1 year (Hari
and Akos, 1989), and continued to attend blocks of therapy at a regional
centre. From the beginning of his school career, Michael attended an
additionally resourced setting where a wide range of children were
educated together. Physiotherapy, speech and language therapy, psycho-
therapy, nursing and enhanced adult : student ratios were available as
part of the usual school provision.
From the start of Michael’s schooling, his parents challenged the local
authority and the school to ensure that Michael got as much support as
possible. They had used the legal recourse available in the UK to ensure
248 Neuropsychological Rehabilitation of Childhood Brain Injury
Summary of Intervention
The educational neuropsychologist visited the three main settings where
Michael spent time: school, home and conductive education centre. In
each setting he was observed doing his usual activities, and discussions
were had with Michael and the adults who knew him well. This enabled
the educational neuropsychologist to develop a broad picture of the
common issues, as well as differences in views, about Michael. The role
was then to act as a mediator, sharing targets and strategies between set-
tings. In most cases, all involved agreed on what should be done next
with Michael, for example helping him to develop a routine for brush-
ing his teeth supported by a strip of pictures and an agreed reward. The
only area where this approach did not result in shared aims was around
motor skills. The physiotherapy provided in school was not compatible
with the conductive education methods, and it was a step too far for
either side to accept strategies from the other.
Educational Neuropsychology 249
The new technique, introduced to the family and the school together,
was precision teaching. Although the school had a long and successful
history of special needs education, the staff were not familiar with preci-
sion teaching, which is one of the few techniques to be directly validated
for children with brain injuries (Chapman et al., 2005). The educational
neuropsychologist led a training session in school for five school staff
and Michael’s mother. They tried out the techniques using role play, with
Michael’s mother pairing up with the school’s special educational needs
coordinator. The school suggested some adaptations to make the charts
more visually accessible for Michael, which were agreed by everyone.
After a further home visit and conversation with school, it was agreed
that the situation was much improved and the educational neuro-
psychologist’s involvement was no longer needed.
Outcomes
At school, Michael’s academic progress was slow but steady. Precision
teaching was being used at home and at school, with success. One
example given by Michael’s mother was that he could name colours
consistently, which he could not do before precision teaching of this
skill. Both school and home reported that they were using precision
teaching with other children too (Michael’s brother was learning his
multiplication tables using the timed probes and charting the results).
From a position of very low trust between home and school, by
the end of the educational neuropsychologist’s involvement the two
reported that they were communicating more openly and agreeing the
plan for Michael rather than having separate home and school plans. At
the beginning of involvement, Michael’s mother was considering mov-
ing him to a different school but he stayed in the same primary school
until the end of the age range there.
Reflection
Overall, the initial aims of involvement were met over the course of
12 months, with school and home no longer requiring the educational
neuropsychologist to mediate a shared plan for Michael. This case illus-
trates many of the areas where an educational neuropsychologist can
provide specialist intervention, as summarised in Table 12.3.
The case is now closed to the educational neuropsychologist,
although the rehabilitation programme continues and the family may
request further support in future, perhaps in planning transition to a
secondary school setting.
250 Neuropsychological Rehabilitation of Childhood Brain Injury
Assessing the best fit between Reassuring both school and parents that
an educational setting and a the placement was appropriate for Michael:
student he was happy and progressing there
Ensuring that educational staff Reminding staff that Michael’s complex
understand the impact of a difficulties were the consequences of a
student’s brain injury on his/her brain injury, which helped to frame his
learning and behaviour needs and his family’s anxiety to get the
provision right for him
Supporting teachers to plan Validating the existing individual
appropriate teaching strategies educational plan and adding a new
and targeted interventions evidence-based strategy to help towards
the targets in the plan
Ensuring that the right Michael already had access to excellent
educational resources are in place resources within his school, including
(this may include reassurance additional one-to-one support, so staff and
that provision can be made from parents could be reassured that they no
existing resources, as well as longer needed to spend their energy on
re-presenting assessment evidence fighting for resources
to meet criteria for additional
resources)
Developing joint intervention Michael’s plans are now jointly agreed
plans with schools and families rather than separate home and school
plans, although conductive education
plans are still separate
In a wider sense, this case raises some issues for professional neuro-
psychology. If Michael was living in a country where educational psycho-
logists cannot train to become neuropsychologists, would the outcomes
have been different? He already had access to an educational psychologist
linked with his school, but this had not resolved the presenting problems.
In this case, the outcomes were improved by the psychologist’s expertise
in both education and brain injury.
A further issue raised by this case is equality of access to educational
neuropsychology services. Michael had private funding, which enabled
his case manager to bring in an educational neuropsychologist for this
work. However, in the public sector, there is no structure in most coun-
tries for ensuring that children can access educational neuropsychology,
and it depends whether there is a local educational psychologist who
happens to specialise in neuropsychology. Localities and regions may
need to work together to coordinate access (see, e.g., Glang et al., 2004).
Educational Neuropsychology 251
Future Directions
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