CHAPTER 10

School Reentry for Children I Recovering from

Neurological Conditions

H. THOMPSON PROUT, GINGER DEPP CLINE, and SUSAN M. PROUT

Students with various neurological conditions may be absent from school for some time due to their illness or injury. This chapter will highlight several medical conditions such as meningitis, sickle cell disease and stroke, childhood cancer, and traumatic brain injury that are known to cause secondary neuropsychological deficits. Depending on the chronicity or longer term effects of these conditions, students may qualify for educational services under Section 504 of the Rehabilitation Act of 1973 or through Individuals with Disabilities Education Act as a student with an Other Health Impairment (OHI) or Traumatic Brain Injury (TBI) if a negative educational impact can be demonstrated subsequent to the health condition or head injury. The purpose of this chapter is to discuss the neuropsychological aspects of four impair­ments (meningitis, sickle cell disease and stroke, cancer, and traumatic brain injury) that typically involve school absence and often have neuro­psychological residuals. Additionally, issues with school reentry and roles fora school neuropsychologist in the reentry process will also be discussed.

MENINGITIS

Meningitis, an infection of the membranes in the brain, has several causative agents, including viruses, fungi, traumatic brain injury, and surgery. However, bacterial meningitis is the most common form, affecting 10 to 30 individuals I per 100,000 (Palumbo, Davidson, Peloquin, & Gigliotti, 1995). The three most common variants include Haemaphilus influenzae B, Neisseria meningitis, and

207

208 Practice Issues in School Neuropsychology

Streptoccus pneumonia (Berg, Trollfors, Hugosson, Fernell, & Svensson, 2002). A vaccination was introduced in 1993, which helped to reduce the incidence! (Koomen et al, 2005); however, certain populations remain at risk (e.g., the very young, very old, and any person who is immunosuppressed) with mortality rates ranging from 5 to 20 percent (Palumbo et al., 1995).

Initial symptoms of meningitis typically include an upper respiratory infection with progression to neck rigidity, irritability, fever, loss of appetite, headache, and light/sound sensitivity. Standards of care in assessment and treatment include a lumbar puncture and high-dose antibiotics. With the advent of more efficacious treatment, more children/adolescents are requir­ing long-term services following neurocognitive effects from meningitis (Koomen et al., 2005).

Effects of Meningitis

Patients have been found to have more abnormal neurological exams than controls and significantly lower IQ scores (Casella et al., 2004). Functionally, children with a history of meningitis have repeated more grades and been referred more frequently for special education services (Koomen, Grobbee, Jennekens-Schinkel, Roord, & van Furth, 2003). Long-term effects may occur in 25 to 35 percent of patients, including seizures (15 to 25 percent), hydrocephalus (30 percent), sensorineural hearing loss, blindness, cranial nerve damage, cerebral palsy, symptoms of inattention and hyperactivity/ impulsivity, learning disabilities, mental retardation, motoric disabilities, and deficits in visuomotor coordination, general cognition, processing speed, motor steadiness memory, executive functioning, and behavioral competence (Casella et al., 2004; Koomen, van Furth, et al., 2004; Palumbo et al., 1995). Anderson, Anderson, Grim wood, and Nolan (2004) followed up children who had meningitis at a young age, twelve years after their illness. They found that these children continued to show neurobehavioral sequelae into adolescence. The deficits were not considered severe com­pared to typically developing peers, but the adolescents with a history of meningitis were twice as likely to need special services. The most notable residuals were deficits in the executive functioning domain. Identified risk factors for negative effects included male gender, young age at diagnosis, acute neurological symptoms, and having Streptoccus pneumonia (Koomen, Grobbee, et al., 2004). Children whose meningitis involved additional medical complications (e.g., seizures, hemiparesis, coma) were found to have deficits on several nonverbal tasks, were rated as performing less well in school, and showed lower levels of adaptive behavior (Taylor, Barry, & Schatschneider, 1993). Taylor, Minich, and Schatschneider (2000) found indications that children with a history of meningitis appeared to be at

School Reentry for Children Recovering from Neurological Conditions 209

risk for "late-emerging" sequalae. Last, there also appeared to be some ■justment issues for children who have had meningitis. Shears, Nadel, ledhill, Gordon, and Garralda (2007) followed up on a cohort of children Id adolescents one year after having meningitis. In over half of the younger Ifldren (under age 6), there were indications of psychiatric disorders, most Hkbly depressive, oppositional defiant, and anxiety disorders sometime

_К ring the year, with disorders persisting for about one-third of the children pie one-year point. About one-quarter of the older children were expe-ncing some type of disorder after one year.

Hdol Reintegration Following Meningitis

nth known challenges, an individualized plan put in place by medical and ■rational professionals for reintegration into the schools and everyday

■ is important for survivors of meningitis. Close communication begins ■h notification and preventive medication for students who were in close proximity to the affected student. Treatment for the affected student may ■lire an extended absence, thus homebound/hospital school services

■ be appropriate once he or she is neurologically stable. Supplementary mpport services may also be initiated while the student is recovering and вроп school reentry (e.g., physical therapy [PT], occupational therapy [ОТ], speech/language therapist [SLT]). Furthermore, an audiological Ща is recommended for all children/adolescents with meningitis due to ■ehigh frequency of hearing loss (5 to 20 percent) (Berg et al., 2002).

IKoomen, van Furth, et al., (2004) viewed a comprehensive neuro-

■chological evaluation as essential to allow for the planning of an individ-

Itialized education plan (IEP) or Section 504 support services (U.S. Department

Education, n.d.). While this may be useful in some cases, the need for a

complete neuropsychological battery should be based on the individual case

В the point in recovery. Based on common neurocognitive effects, the

Mowing recommendations may be appropriate: giving directions in quiet

Kings without distractions, shortened/direct instruction to assist with

[auditory attention/processing weaknesses, and shortened assignments to

■mmodate decreased motor and/or visuomotor skills (Grimwood et al.,

B). Education for staff is certainly essential for understanding the child's

edition and subsequent impact on learning. With parental permission,

preparation for classmates may be beneficial in establishing a supportive

■al environment for the student's return (Koomen et al., 2005; Palumbo

■1., 1995). Finally, frequent monitoring of progress is essential to allow for

■Evolving plan of support with appropriate expectations and an under-

■tding of current needs. Until specific cognitive skills are challenged, some

fenptoms/difficulties may not be apparent.

210 Practice Issues in School Neuropsychology

SICKLE CELL DISEASE AND STROKE

Sickle cell disease (SCD) or anemia is a genetic blood disorder yielding an abnormal form of hemoglobin, which interferes with oxygen transportation throughout the body. The variants of SCD affect diverse ethnic groups including a predominance in African American (1:396) and Latino (1:36,000) populations (Lindsey et al, 2005). Pain crises are common due to sicklingof hemoglobin S and obstruction to blood flow (Morse & Shine, 1998). Most children/adolescents with SCD are at risk for stroke, which occurs when there is a diminished supply of blood to the brain (Phelps, 1998). By 14 years of age, 11 percent of individuals with SCD will have an overt stroke, while 22 percent will experience a silent stroke by the age of 18 years (Berkelhammer et al., 2007; Lindsey et al., 2005). DeBaun, Derdeyn, and McKinstry (2006) noted that 30 I percent of persons with SCD will experience a stroke at some point in their I lifetime, which typically occurs relatively early in their development. Silent I strokes are diagnosed when MRI results are suggestive of stroke within the I context of a normal neurological exam and no known history of stroke (Schatz, I Brown, Pascual, Hsu, & DeBaun, 2001).

Effects of Sickle Cell Disease and Stroke

Resultant deficits following a stroke depend on the particular area of insult I General intellectual functioning has been found to be reduced (i.e., 10 to 15 I point loss), along with accompanying difficulties in academic skills (e.g.,1 recommendations for special education and retention), attention and exec- I utive functioning, visual-motor integration, language skills, behavioral regu- I lation, and memory (King, Tang, Ferguson, & DeBaun, 2005; Schatz к I McClellan, 2006). Frontal lobe damage is associated with skill loss in memory I and attention, while more diffuse damage of the frontal and parietal lobes I leads to increased difficulties with memory, attention, and visual-spatial I processing (King et al., 2006). Effects from silent strokes seem to be less I severe, but have similar outcomes to those of overt strokes (Schatz к I McClellan, 2006).

School Reintegration Following Sickle Cell Disease and Stroke

Based on these risks, students with SCD who experience a stroke are more I likely to require specialized services upon their return to school, possibly I qualifying for special education under the Other Health Impairment (OH) I category or through Section 504. Intensive educational planning including I professional education regarding SCD and stroke is essential for school staff I (King et al., 2006). Teacher awareness of early warning signs of stroke may I lead to early recognition of a stroke. Signs of a stroke may include sudden I

School Reentry for Children Recovering from Neurological Conditions 211

weakness/numbness of a part or side of the body, sudden loss of vision or speech, difficulty talking or understanding others, a severe headache, and unexplained dizziness/falls. Symptoms of a silent stroke include a general decease in performance, increased forgetfulness, and difficulty following directions (Lindsey et al., 2005). Frequent absences due to pain crises may also warrant occasional homebound educational services, and teachers should be aware of health precautions for students with SCD (e.g., avoiding tempera­ture extremes, drinking plenty of water) (King et al., 2005). Accurate knowl­edge about SCD and its effects will lead to more positive/situational educational outcomes for students. King et al. (2006) highlighted a program that was developed to increase teacher knowledge about this condition with significant, positive effects.

Following a stroke, a comprehensive neuropsychological exam is often viewed as essential to allow for individualized planning for areas of support along with frequent monitoring, assessing for continuing improvement and need for services (King et al., 2005, 2006). Again, the need for full neuro­psychological evaluation is contingent on the specific aspects of an individ­ual child's condition. Specific accommodations /modifications may include resource room instruction, extended time, preferential seating, attentional strategies, note-taking assistance, computer assistance, homebound instruc­tion, and related service support (e.g., ОТ, РТ, SLT) (King et al., 2005,2006). Psychosocial support for students with SCD and stroke may also be necessary in order to strengthen/support coping strategies, adjustment skills (e.g., related to pain, delayed growth/puberty, changes following a stroke), and peer relationships. Support in both school and clinical settings is optimal.

CANCER

Children/adolescents are diagnosed with numerous forms of cancer, or abnormal cell growth, each year. Malignancies of the blood are the most common childhood cancer diagnoses, followed by solid tumors (Li & Wendt, 1998). The National Cancer Institute (n.d.) reports that the incidence of childhood cancer has risen slightly in recent years (11.5 per 100,000 children in 1975 to 14.8 per 100,000 in 2004). Death rates have declined dramatically in approximately the same time frame with five-year survival rates increasing from 58.1 to 79.6 percent. While survivability has improved significantly, radical/intense treatments may have residual effects (Reinfjell, Lofstad, Veen-stra, Vikan, & Diseth, 2007). It is often the nature of and the associated residuals of the treatments that impact neurocognitive functioning. However, brain tumors obviously have the most direct impact on neurocognitive outcome in addition to treatment side effects. The size, location, and extent of the tumor