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• 1 2023-07-05T02:40:20-07:00 Changing our classrooms to address COVID-19’s impact on cognition 7 This article is "Changing our classrooms to address COVID-19’s impact on cognition." This was written by Dr. Jessica A. Cannon. plain 2023-07-05T06:31:11-07:00 By Jessica A. Cannon, Associate Professor of History, University of Central Missouri
  
  
   
  
  
  Figure 1. Learning in the age of COVID-19 (Image by Justin Kilian from Pixabay)
  
  
  
  
  
  
  Three years into the Coronavirus COVID-19 pandemic, we have clearer research detailing the virus’s impact throughout the acute and post-acute infection (also known as Long-COVID) phases. We also have growing evidence that COVID creates long-term disabling conditions for many individuals, including cognitive impairments that are unseen or difficult to quantify. In addition to cognitive dysfunction, other common ongoing symptoms impacting education include hearing loss, limitations on speech (because of breathing difficulties), memory loss or impairment, lack of concentration, reduced stamina and mobility, inability to sleep, and psychological mood disorders like anxiety and depression. As educators, we need to consider this growing population of children and adults impacted by COVID and adapt our learning environments accordingly. What do we need to know, and how might we better support these individuals? This article outlines several takeaways from the medical literature and proposes six avenues for modifying classroom and online activities to better support our students.

  
  Medical Research

  
  A summary of the medical research aids in defining the issues that educators will want to consider moving forward. Many of the symptoms explored below also occur in the acute phase of infection (the 1-4 weeks someone is initially sick), although the focus of this article will be on Long-COVID. COVID-19 is a rare virus in that it binds to ACE2 cells that occur throughout the body (Li, 2020). Given it affects the body more widely than most viruses, and may leave long-term damage, we must understand these complications and in particular the cognitive impacts.
  
  Long-COVID, or post-acute sequelae SARS-CoV-2 (PASC), generally refers to symptoms lasting from several weeks to months or even years after infection. Roughly 1 in 10 people experience multiple, persistent Long-COVID symptoms (Basu-Ray, 2022). There have been at least 50 different symptoms of Long-COVID clinically identified, including in one meta-analysis: 58% of patients experienced fatigue, 44% had headaches or migraines, 27% reported attention disorder, 16% memory loss, and 15% experienced hearing loss or tinnitus (Lopez-Leon, 2021). Recent studies note that 80% of patients who experienced Long-COVID symptoms at 4 months following acute infection were still experiencing symptoms at 24 months from infection, and these were predominately “cognitive, sensorimotor, and fatigue symptoms” (Wahlgren, 2023; see also, Heine, 2023). Mild initial infections do not mean someone will avoid developing Long-COVID symptoms, and reinfection with COVID increases the chances of developing Long-COVID symptoms (Wahlgren, 2023; Bowe, 2022).
  
  There are even indications that the virus is related to increased risk for autoimmune diseases and subsequent diagnosis (within a two-year period) of autoimmune diseases like arthritis, lupus, celiac disease, and multisystem inflammatory syndrome in children (Chang, 2023; Rhedin, 2022). Moreover, there are numerous studies showing COVID-19 increases risk for cardiovascular diseases or events like stroke and pulmonary embolism (Czeisler, 2023; Wang, 2022).
  
  These symptoms can impact learning broadly, but research also focuses specifically on the impact to cognitive function. The “brain fog” commonly reported with COVID-19 infection includes “deficits in attention, executive functioning, language, processing speed, and memory” along with “increased incidence of anxiety, depression, sleep disorder, and fatigue” that correlate to cellular changes in the brain (Venkataramani, 2022). Magnetic-Resonance Imaging (MRI) has measured a physical reduction in brain size along with tissue damage in specific regions of the brain among patients who were scanned both before and after they were infected with COVID-19. Furthermore, these physical changes correlate with outwardly observed cognitive decline for those individuals between the two time points (Douaud, 2022). Other research shows COVID-related brain damage in deceased patients similar to that found in patients with Alzheimer’s disease (Reiken, 2022). In cases where initial infection or reinfection with COVID resulted in hospitalization of individuals, the effects on higher cognitive functions and processing speed recovers much more slowly, if at all (Hampshire, 2022).
  
  Research on mood disorders highlights that our students are also struggling with anxiety and stress. A study of over 81 million patients found 14 different neurological and mood disorder symptoms associated with COVID infection (Taquet, 2021). Among 45,000 French undergraduate students, one study reported “high prevalence rates for stress (20.6%), anxiety (23.7%), depression (15.4%), suicidal thoughts (13.8%), and post-traumatic stress disorder (29.8%)” (Wathelet, 2022). This is in addition to Long-COVID symptoms and brain fog. Brain fog or memory impairment was reported by 46% of people in another study and was directly associated with a lower likelihood of working full-time (Suran, 2023).
  
  In short, the ability to focus or produce work in an education setting is undoubtedly affected. Given the millions of people infected over the last three years, we clearly have students who are dealing with this right now. Because COVID’s effects persist, sometimes permanently, we are and will continue to encounter a growing number of individuals with cognitive dysfunction and other disabilities. We must make accessibility a central tenet of instructional design and teaching to adjust learning environments to this new reality. While efforts in the first 30 years of the Americans with Disabilities Act have often been sporadic, we have a renewed opportunity for educators to lead accessibility efforts on their campuses.

  Accessible learning spaces

   
  
  
  Figure 2. Accessible learning spaces are critical. (Image by Gerd Altmann from Pixabay)
  
   

  Modifying learning environments and activities

  There are structural and institutional changes that would better support accessibility on campuses, some examples of which have been explored in disability studies and other published research (Kerschbaum, 2017; Dolmage, 2017; Cannon, 2023). However, transformational learning in this new global context can also begin within our classrooms and learning environments. As teachers and instructional designers, we have latitude to design with accessibility in mind even when curriculum or other power structures define certain aspects of learning environments. The remainder of this article highlights six avenues of change that serve as catalysts to rethinking how we teach and learn.

  
  1.    WCAG 2.1 and accessibility practices

  
  Luckily, there are numerous accessibility tools and guidelines to inform how we craft learning experiences. The Web Content Accessibility Guidelines (WCAG 2.1) are a gold standard for web accessibility, and a level A or AA score on each criteria is the most common goal. The four tenants of perceivability, operability, understandability, and robust design are an excellent guide even for accessibility novices, while advanced designers might prefer the detailed tests and specific levels of performance for digital materials. The W3C Web Accessibility Initiative, the organization that produces the WCAG guidelines, also provide a list of 84 evaluation tools that check different elements of the guidelines.
  
  
  The Office of Civil Rights recently issued a Dear Colleague Letter to remind colleagues of accessibility requirements for digital programs and activities in higher education, and they released a video series covering almost two dozen accessibility topics to provide guidance on compliance. Between the OCR video series and the W3C Accessibility Fundamentals Overview, there are videos and written descriptions to help anyone begin working towards greater accessibility. A YouTube search for specific WCAG guidelines or questions also provides a wide variety of walk-through demonstrations.
  
  
  Other common accessibility practices in education address the content we create and share. Adding headings to documents, formatting tables appropriately (for example, in the syllabus), adding alternative text to images, and ensuring videos are closed-captioned or providing transcript for video and audio content are among the most common activities teachers need to do with each course. A thorough walk-through of these and other common practices is available on the University of Washington’s IT Accessibility Checklist. Attending to these common practices and using built-in course accessibility checkers in a Learning Management System are an excellent way to make the bulk of a course more accessible. Use the instructional design or technology team at your institution to assist you as well.
   

  2.    Flexibility

  Flexibility and compassion go a long way in supporting students who are struggling. Stressors outside school add cognitive load and distractions for students, and Long-COVID may already be impacting their working memory and ability to process information. By being inflexible, we might inadvertently be asking students to power-through illness or struggles in a case where a few days’ extension does not actually harm anyone. Granted, some teachers believe that students must learn to deal with workload and meet deadlines for future workplace success. Time management is an important skill, but we forget that workplaces often have sick leave, somewhat flexible deadlines, and offer supporting casts through colleagues and team structures.
  
  Moreover, the majority of students today are “non-traditional” students: they have families, work, care-taker responsibilities, or even military service competing for time alongside education. They are already project managers, and education has been slow to acknowledge these realities for the new “traditional” learner or meet them where they are. Providing flexibility and showing empathy results in options to succeed for our students rather than dead ends. When we incorporate accessibility and flexibility from the outset of a course, we keep those options open for everyone—even students without disability documentation (which is often costly to update each year), those who are undiagnosed, or individuals with a changing set of medical challenges.
   

  3.    Universal Design for Learning

  
  Flexibility can also exist in how students demonstrate learning, one of the principles of Universal Design for Learning. UDL stresses pathways for engagement, representation, and action or expression. Pathways create agency and individualized learning that not only motivate students to engage and stay engaged, but they also encourage students to learn from different content materials and demonstrate their skills or learning in a variety of performance or assessment options. When we provide the same information in different formats, students choose the content materials that fit their learning strategies—perhaps a video, a text, a podcast, or an animation. They may opt to read the text and view the video, which is their ideal way of seeing and understanding a concept, where another student needs the animation to understand how something works. With UDL, students are also given multiple ways to demonstrate their learning. The assessment may focus on analyzing and evaluating information and supporting a specific position, but the rubric and instructions are designed to allow students to choose how they share that knowledge—a recorded oral presentation, a paper, a slideshow, poster project, podcast, or something else. The flexibility designed into UDL principles gives students with disabilities the same options to choose materials and demonstrate knowledge in ways that work best for them.
   

  4.    Neurodivergence

  Neurodivergence includes individuals who are autistic, have ADHD, or who have other cognitive issues including dyslexia. Although they make up an estimated 15 to 20 percent of the population, these individuals do not always have a diagnosis—another reason that designing with accessibility from the outset benefits a wide range of people in our classes without us even knowing. Techniques used to assist these individuals include organizational strategies or reminder apps, flexibility in learning spaces or access to content to address sensory issues, and providing clear, direct language in instructions. Incorporating these techniques assists with other disabilities too, like Long-COVID cognitive dysfunction. Moreover, neurodivergent individuals bring unique perspectives to the table, a valuable resource in our collaborative learning communities.
   

  5.    Solid Course Design and Alignment

  Quality assurance models like the Online Learning Consortium's (OLC’s) OSCQR or Quality Matters(R) stress alignment between learning outcomes, course materials, and assessments because clarity is vital to student success. Solid course design—where the logic and connections that inform the design of the course are shared with students—allows students to understand what they are to be doing and how it all fits together. Students probably will be working on course activities in fits-and-starts between many other demands in their lives, and using rubrics, model assignments from prior students, and clear learning outcomes provides the opportunity to self-check their learning after each step. The importance of these tools cannot be underestimated; brain fog adds layers of confusion to even a well-designed course.
  
  
  Another dynamic to consider when creating course materials is Mayer’s Principles for Multimedia Learning. Mayer’s Principles include several key concepts, for instance that students learn best when visual information is presented at the same time as either audio narration or text—but not all three together, and visual with audio is the best combination. The content being described in the audio should also be synchronized with the visuals, and all other distractions should be minimized (for instance, background music, extraneous images or text, etc.). Additionally, students learn best when the visuals assist in organizing the information or relating it to other concepts or information. The more you demonstrate the action or process you are describing, including using arrows and pointing out key connections, the more likely it is that students will take away what you want them to achieve with the materials.
  
  
  The foundation supporting Mayer’s work is Cognitive Load Theory, which relates to limiting the number of things we are asking students to think about or do at any given point in time to facilitate learning. Importantly, this also mediates the effects of cognitive dysfunction from something like Long-COVID. Brain fog, concentration challenges, and memory loss also limit how much information can be processed in working memory. 
   

  6.    Leveraging Ed Tech

  An ever-growing number of Ed Tech tools are available to facilitate collaborative learning or that are built on research principles like spaced-retrieval and deliberate practice. Through providing guidance on student choices of effective study tools, teachers facilitate students learning to monitor their own learning or select alternative paths that work best for them. Artificial Intelligence and Language Learning Models may be another avenue to assist individuals with disabilities by increasing feedback and adaptive learning options or providing suggestions on language and topic exploration. Leveraging technologies to transform and provide options for students across skill levels and platforms is possible with free resources in ways that did not exist before COVID. At the same time, we want to be sure that we utilize technology for transformative learning not simply to add technology to a course (and inadvertently add cognitive load and stress for our students). The SAMR model and the Technology Integration Matrix are two tools to evaluate integration of technology with learning goals and aid in making decisions.
  
  
   

  Conclusion

  
  COVID-19 creates long-term disabling conditions and reasserts the need for society to live up to the ideals and expectations of the Americans with Disabilities Act (1990). Adapting classrooms and learning environments for the growing number of individuals with cognitive dysfunction includes changes that benefit many other disabilities. At the same time, focusing on practices that limit cognitive load, provide flexibility, and facilitate learning through clear course design can make a significant difference for students dealing with COVID complications. The six catalysts explored in this article—WCAG 2.1 and existing accessibility practices, flexibility and compassion, Universal Design for Learning, considering neurodivergence, solid course design and alignment, and leveraging Ed Tech—are avenues that can support educators in leading change.
  
  
  Author Note
  Numerous additional studies are available but not referenced here for space considerations. An ongoing list of categorized Long-COVID medical research is maintained by the author here.
  
  
   

  References

  
  Basu-Ray, I., Almaddah, N. K., Adeboye, A., & Soos, M. P. 2023. Cardiac manifestations of coronavirus (COVID-19). National Library of Medicine (NIH). https://www.ncbi.nlm.nih.gov/books/NBK556152/
  
  Bowe, B., Xie, Y., Al-Aly, Z. 2022. Acute and postacute sequelae associated with SARS-CoV-2 reinfection. Nature Medicine, 28, 2398-2405. https://doi.org/10.1038/s41591-022-02051-3
  
  Cannon, J. A. 2023. Revisioning accessibility in higher education post-COVID-19. In Hai-Jew, S. (Ed.). Handbook of research on revisioning and reconstructing higher education after global crises (pp.22-33). IGI Global. https://doi.org/10.4018/978-1-6684-5934-8.ch002
  
  Chang, R., Chen, T. Y., Wang, S., Hung, Y., Chen, H., Wei, C. J. 2023. Risk of autoimmune diseases in patients with COVID-19: a retrospective cohort study. eClinicalMedicine, 56. https://doi.org/10.1016/j.eclinm.2022.101783
  
  Czeisler, M., & Ibrahim, S. A. 2023. Cardiovascular risk in patients with post-COVID-19 condition. JAMA Health Forum, 4(3). https://doi.org/10.1001/jamahealthforum.2022.4664
  
  Dolmage, J. T. 2017. Academic ableism: Disability and higher education. University of Michigan Press.
  
  Douaud, G., Lee, S., Alfaro-Almargo, F., et al. 2022. SARS-Cov-2 is associated with changes in brain structure in UK Biobank. Nature, 604, 697-707. https://doi.org/10.1038/s41586-022-04569-5
  
  Hampshire, A., Chatfield, D. A., Manktelow, A., Jolly, A., Trender, W., Hellyer, P. J., et al. Multivariate profile and acute-phase correlates of cognitive deficits in a COVID-19 hospitalised cohort. eClinicalMedicine, 47. https://doi.org/10.1016/j.eclinm.2022.101417
  
  Heine, J., Schwichtenberg, K., Hartung, T. J., Rekers, S., Chien, C., Boesl, F., et al. 2023. Structural brain changes in patients with post-COVID fatigue: a prospective observational study. eClinicalMedicine, 58. https://doi.org/10.1016/j.eclinm.2023.101874
  
  Kerschbaum, S. L., Eisenman, L. T., & Jones, J. M. (Eds.). 2017. Negotiating disability: Disclosure and higher education. University of Michigan Press.
  
  Li, M., Lin, L., Zhang, Y., & Wang, X. 2020. Expression of the SARS-CoV-2 cell receptor gene ACE2 in a wide variety of human tissues. Infectious Diseases of Poverty, 9(45). https://doi.org/10.1186/s40249-020-00662-x
  
  Lopez-Leon, S., Wegman-Ostrosky, T., Perelman, C., Sepulveda, R., Rebolledo, P. A., Cuapio, A., & Villapol, S. 2021. More than 50 long-term effects of COVID-19: a systematic review and meta-analysis. Scientific Reports, 11(1), 1-12. https://doi.org/10.1038/2Fs41598-021-95565-8
  
  Reiken, S., Sittenfeld, L., Dridi, H., Liu, Y., Liu, X., & Marks, A. Alzheimer’s-like signaling in brains of COVID-19 patients. Alzheimer’s & Dementia, 18(5), 955-965. https://doi.org/10.1002/alz.12558
  
  Rhedin, S., Lundholm, C., Horne, A., Smew, A., Osvald, E. C., Haddadi, A., et al. 2022. Risk factors for multisystem inflammatory syndrome in children- A population-based cohort study of over 2 million children. The Lancet Regional Health, 19. https://doi.org/10.1016/j.lanepe.2022.100443
  
  Suran, M. 2023. Long COVID linked with unemployment in new analysis. JAMA, 329(9), 701-702. https://doi.org/10.1001/jama.2023.0157
  
  Taquet, M., Sillett, R., Zhu, L., Mendel, J., Camplisson, I., Dercon, Q., et al. 2022. Neurological and psychiatric risk trajectories after SARS-CoV-2 infection: an analysis of 2-year retrospective cohort studies including 1,284,437 patients. The Lancet Psychiatry, 9(10), 815-827. https://doi.org/10.1016/S2215-0366(22)00260-7
  
  Venkataramani, V., & Winkler, F. Cognitive deficits in Long COVID-19. The New England Journal of Medicine, 387, 1813-1815. https://doi.org/10.1056/NEJMcibr2210069
  
  Wahlgren, C., Forsberg, G., Divanoglou, A., Balkhed, A. O., Niward, K., & Berg, S. 2023. Two-year follow-up of patients with post-COVID-19 condition in Sweden: a prospective cohort study. The Lancet Regional Health, 28. https://doi.org/10.1016/j.lanepe.2023.100595
  
  Wang, W., Wang, C., Wang, S., & Wei, J. C. 2022. Long-term cardiovascular outcomes in COVID-19 survivors among non-vaccinated population: A retrospective cohort study from the TriNetX US collaborative networks. eClinicalMedicine, 53. https://doi.org/10.1016/j.eclinm.2022.101619
  
  Wathelet, M., Horn, M., Creupelandt, C. et al. 2022. Mental health symptoms of university students 15 months after the onset of the COVID-19 pandemic in France. JAMA Netw Open, 5(12). https://doi.org/10.1001/jamanetworkopen.2022.49342
  
   

  About the Author

  
  
  
  
  Dr. Jessica Cannon is an Associate Professor of American History at the University of Central Missouri. She holds a Ph.D. in History, an Assistive Technology Specialist certification from Cal State University Northridge, and is working on a second master’s degree, M.S. in Educational Technology, to be completed in December 2023. She is a Quality Matters Master Reviewer (since 2016) and has completed numerous courses through OLC, including the Instructional Designer Certificate.