Role of the Speech-Language Pathologist in
the Recovery Process of Individuals with
Traumatic Brain Injury
JESSICA D. RICHARDSON, PH.D., CCC-SLP
ASHA Scope of Practice
 ASHA = American Speech-Language-Hearing
Association

Scope of practice:
http://www.asha.org/uploadedFiles/SP2007-00283.pdf
 Narrative Samples
Functional outcomes and reimbursement trends
 Trend of reduced resources available for
rehabilitation
 Trend of increased demands for improved functional
outcomes
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Lessening activity/participation limitations is focus instead of
traditional focus of eliminating/reducing the underlying
impairment.
Treatment effectiveness is therefore demonstrated by
meaningful improvements in the tasks of everyday life.
www.asha.org/policy/
Functional outcomes and WHO-ICF
 World Health Organization – International
Classification of Functioning, Disability, and Health
(WHO-ICF)

Classification system that describes disorders in terms of
resultant limitations placed upon the individual
Limitations in body function and structure
 Activity limitations
 Participation limitations
 Contextual factors

WHO-ICF: Limitations in body
structure/function
 Previously known as “impairment”
 Underlying damage to psychological, physiological,
or anatomic structures or functions

e.g., inability to hold more than 6 items in memory, increased
distractibility, word-finding deficits/anomia
WHO-ICF: Activity limitations
 Previously known as “disability”
 Functional consequences of the limitations of
body function and structure

e.g., limitation of body structure and function =
anomia/word-finding problem; resultant activity
limitation = unable to add ideas or take turns in
conversation
 Predictive of participation limitations
WHO-ICF: Participation limitations
 Previously known as “handicap”
 Tied to one’s well-being and social
consequences that arise from having cognitive
disorder; discussed relative to life roles

e.g., Can the individual with a TBI still lead meetings,
conduct class lessons, drive a truck (long-haul), etc.? If
not, then participation in pre-TBI life activities is
limited.
WHO-ICF: Contextual factors
 Social, familial, educational, vocational, or other
role disadvantage associated with the disability

e.g., failure in school, loss of job
 Includes also:
 Environmental factors


factors not within the person’s control (e.g., attitudes of
individuals in the environment, family, work, government
agencies, laws, cultural beliefs, etc.)
Personal factors

e.g., attitudes of individual with TBI, race, gender, age,
educational level, coping styles, etc.
Flow of clinical services
 1 - Pre-assessment.
 2 - The development of a clinical question regarding
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diagnosis, intervention, and/or discharge.
3 - Selection of assessment instruments.
4 - Assessment.
5 - Using the information to determine intervention
approach.
6 - Intervention.
7 - Re-assessment.
…
1 - Pre-assessment
 Thorough pre-assessment improves quality of
assessment process and information gained
 Especially important in TBI

history, substance abuse, depression, etc.
 Sources of pre-assessment information can include:
 Written case history
 Interview with client and caregivers


Who is concerned about the client’s communication performance
(client, other health professional, family member, etc.)? Why are
they concerned?
Interview/Information from other professionals, Medical
records
2 - Development of clinical question
 This is also Step 1 of evidence-based practice: “The
development of a clinical question regarding
diagnosis, intervention, and/or discharge.”



Does the person potentially have a disorder that falls under my
scope of practice?
If yes, what domains seem to be affected?
What additional information do I need to obtain in order to
have sufficient information for determining if the person
actually has one or more disorders?
3 – Selecting your assessment measures
 Before using a standardized assessment measure, need to
determine whether or not it is the appropriate measure
to administer.
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What is the purpose of the test?
How was the test constructed/developed?
What are the administration and scoring procedures?
What is the normative sample group?
Is this a valid test?
Is this a reliable test?
Which domain of WHO-ICF limitations does this test assess?
 Will also need to use nonstandardized assessment
measures
4 - Assessment (1)
 Traditionally, assessment has involved:
 Battery of tests of neuropsychological/cognitive/linguistic
function to identify strengths and weaknesses (i.e., limitations
of body structure/function)
 Improved approach includes contextualized
measures (aka “authentic” measures)

Arose because research has demonstrated that aforementioned
assessment approach does a poor job assessing functional,
real-world outcomes and/or long-term maintenance of
treatment gains and does not assist with vocational planning
 http://tbims.org/combi/list.html
4 - Assessment (2)
Standardized tests to identify deficits and to
generate hypotheses about areas to target in
rehabilitation
1.
1.
*comment on aphasia batteries for TBI
2. Situational observation
i.
To confirm and enrich OR negate test findings
ii. Why?
4 - Assessment (3)
3. Ongoing contextualized hypothesis testing
i.
Systematic exploration of strategies, task modifications,
supports, intervention procedures, etc. that could positively
influence task performance and learning
ii.
Why ongoing and contextualized?
iii. Why hypothesis testing?
4 - Assessment (4)
4. Measure the knowledge and support skills of the
people in the everyday life of the person with TBI
4 - Assessment (5)
5. Collaboration with other professionals
6. Collaboration with the patient
Collaborating with the patient in the following is important
for both assessment and treatment:
i.
i.
ii.
iii.
iv.
ii.
Goal-setting
Testing intervention hypotheses
Exploring strategic compensations
Monitoring outcomes
Evidence that direct patient involvement in
neurorehabilitation goal setting => maintained goals at
follow-up
Big Picture
Rehabilitation Coordinator/Case Manager
Primary
Physician
Neuropsychologist
Psychologist
Nurse
Medical
Consultants
Physical
Therapist
Patient
Occupational
Therapist
Speech
Pathologist
Social
Worker
Recreation
Therapist
Vocational
Specialist
Nutritionist
Source: Christine C. O’Hara and Minnie Harrell, Rehabilitation with Brain Injury Survivors: An Empowerment Approach, Aspen Publishers, Inc., 1991.
4 - Assessment (6)
 Why are all of these team members involved?

Primary Consequences
 Penetrating Head Injury (Low-velocity, High-velocity)
 Nonpenetrating (or closed) Head Injury (Nonacceleration,
Acceleration [linear, angular])
• Diffuse Axonal Injury
Some Secondary Consequences (brain’s responses to primary trauma,
often more devastating than primary consequences)
 Traumatic hemorrhage, cerebral edema, traumatic hydrocephalus,
increased intracranial pressure, ischemic brain damage, cerebral
vasospasm
 Resultant Systemic complications
 Skin, eye, ear, nose, mouth and throat, larynx, trachea, lungs, GI
tract, heart, PVS, genitourinary system, female reproductive
system, metabolic-endocrine system, blood, musculoskeletal
system, PNS, CNS

4 - Assessment (7)
 Assessment and Intervention Environments
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Acute setting
Post-acute/sub-acute facilities
Day treatment/outpatient services
Group home/residential living
Vocational rehabilitation
Transitional living
Protected work trial
School
Private clinic
Behavior management
Pediatric programs
Brain injury + other conditions
Respite
4 – Assessment (8)
 Assessment and Intervention will depend upon stage
of recovery, e.g.,
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STAGE 1 – “Comatose and Semi-Comatose”
STAGE 2 – “Responsive and Agitated”
STAGE 3 – “Restless and Distractible”
STAGE 4 – “Oriented, Purposeful”
STAGE 5 – “Dependent”
STAGE 6 – “Semi-Independent”
Also, Rancho Los Amigos Levels of Cognitive Functioning (p.
425)

http://www.rancho.org/research/cognitive_levels.pdf
5 - Determine Intervention Approach
 Differential Diagnosis
 Comorbid Diagnoses
 Limitations and Contextual Factors
 Hierarchy of Clinical Importance/Personal
Importance


The “whole picture”
Prioritize immediate and less-immediate needs
6 – Intervention
 To discuss
7 - Re-assessment
 Remember, assessment should be ongoing
 Also, the final stage of evidence-based practice is to
evaluate whether or not the chosen approach is
working and to make modifications as necessary.
6 – Intervention
EVIDENCE-BASED RECOMMENDATIONS
 Cognitive Rehabilitation Task Force of the American
Congress of Rehabilitation Medicine Brain Injury
Interdisciplinary Special Interest Group (Cicerone et al.,
2011, Arch Phys Med Rehabil)
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ATTENTION
VISION and VISUOSPATIAL FUNCTIONING
LANGUAGE AND COMMUNICATION SKILLS
MEMORY
EXECUTIVE FUNCTIONING
COMPREHENSIVE-INTEGRATED NEUROPSYCHOLOGIC
REHABILITATION
EVIDENCE-BASED RECOMMENDATIONS
 Practice Standards
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At least 1 well-designed Class I study with adequate N
Additional support from Class II or Class III evidence
Directly addresses treatment effectiveness
Substantive evidence of effectiveness
 Practice Guidelines
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1 or more Class I studies with methodologic limitations OR welldesigned Class II studies with adequate N
Directly addresses treatment effectiveness
Evidence of probably effectiveness
 Practice Options
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Class II or Class III studies
Directly addresses treatment effectiveness
Evidence of possible effectiveness
TBI and COMMUNICATION
TBI and Communication (1)
 Speech Impairment – a problem with voice, fluency,
and/or how a person says speech sounds.
 Language Impairment – a problem with
understanding and/or using spoken, written,
and/or other symbol systems.



Form – the rules about how sounds are combined, how words
are constructed, and how we combine words to form
sentences.
Content – the meanings of words.
Function – using language (form and content) to
communicate in functional and socially appropriate
ways.
TBI and Communication (2)
 Low incidence of aphasia secondary to TBI
 Communication problems secondary to TBI are quite
different from aphasia, BUT aphasia assessment
batteries are commonly administered


Problem with aphasia test batteries
"Performance on aphasia batteries may give the impression that
their communicative skills are intact. However, interactions with
many of the same individuals leave the listener with the sense that
they are off target, tangential, and disorganized or, in some cases,
have very little to say. The overestimated communicative
performance of these individuals is a function of the limited scope
and ceiling effect of aphasia batteries, which were never intended to
assess the subtle types of deficits many individuals with TBI
demonstrate.” Coelho et al., 2005, Seminars in Speech and
Language
 Impaired discourse is the hallmark of post-TBI
cognitive-communication disorder
TBI and Communication (3)
 Discourse abilities reside at crossroads of
language and cognition
 Anatomy:

Lateral and medial prefrontal cortices (LPFC, MPFC)

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Dorsolateral LPFC
Temporoparietal and anterior temporal regions
Posterior cingulate
Connections between these areas, and from these areas
to other lobes
TBI and Communication (4)
 Discourse Impairment
 Macro-linguistic deficits

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Difficulty with inference

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Reduced cohesion and coherence; impaired organization; problems
with story components and grammar
Impaired social cognition
Reduced information and efficiency
Tangential language, difficulty identifying communication
breakdowns and repairing
 Shorter and less complex utterances
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Reduced initiation and maintenance
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Dependent on others to maintain flow of conversation
Micro-linguistic deficits

Meaning within words, phrases, sentences
TBI and Communication (4)
 Discourse Impairment
 Macro-linguistic deficits


Difficulty with inference


Reduced cohesion and coherence; impaired organization; problems
with story components and grammar
Impaired social cognition
Reduced information and efficiency
Tangential language, difficulty identifying communication
breakdowns and repairing
 Shorter and less complex utterances


Reduced initiation and maintenance


Dependent on others to maintain flow of conversation
Micro-linguistic deficits

Meaning within words, phrases, sentences
TBI and Communication (4)
 Discourse Impairment
 Macro-linguistic deficits


Difficulty with inference


Reduced cohesion and coherence; impaired organization; problems
with story components and grammar
Impaired social cognition
Reduced information and efficiency
Tangential language, difficulty identifying communication
breakdowns and repairing
 More turns of shorter and less complex utterances


Reduced initiation and maintenance


Dependent on others to maintain flow of conversation
Micro-linguistic deficits

Meaning within words, phrases, sentences
TBI and Communication (4)
 Discourse Impairment
 Macro-linguistic deficits


Difficulty with inference


Reduced cohesion and coherence; impaired organization; problems
with story components and grammar
Impaired social cognition
Reduced information and efficiency
Tangential language, difficulty identifying communication
breakdowns and repairing
 Shorter and less complex utterances


Reduced initiation and maintenance


Dependent on others to maintain flow of conversation
Micro-linguistic deficits

Meaning within words, phrases, sentences
TBI and Communication (4)
 Discourse Impairment
 Macro-linguistic deficits


Difficulty with inference


Reduced cohesion and coherence; impaired organization; problems
with story components and grammar
Impaired social cognition
Reduced information and efficiency
Tangential language, difficulty identifying communication
breakdowns and repairing
 Shorter and less complex utterances


Reduced initiation and maintenance


Dependent on others to maintain flow of conversation
Micro-linguistic deficits

Meaning within words, phrases, sentences
TBI and Communication (5)
 EBRs
 Practice Standards

Cognitive-linguistic therapy

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Acute, postacute
Intervention to improve social communication skills
 Practice Guidelines
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Intervention for specific areas of deficit (e.g., reading, word-finding,
narrative production)
Treatment intensity is a key factor
 Practice Options
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Group-based intervention for language and social-communication
deficits
Computer-based interventions as an adjunct to clinician-guided
treatment of cognitive-linguistic deficits
TBI and Communication (6)
 Types of tasks
 Social skills training
Pragmatic communication behaviors
 Listening, starting a conversation
 Social perception of emotions and social inferences
 Psychotherapy for emotional adjustment
 Self-instructional training strategies for emotion perception
deficits (metacognitive strategies)


Narrative, conversation
TBI and EXECUTIVE
FUNCTION
What are executive functions?
 Executive functions = “superordinate,
managerial capacity for directing more modular
abilities, including language, memory, motor
skills and perception in the service of managing
and attaining goals” (p 487)
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Maintenance of a problem-solving set for future goals
(working memory)
Set shifting
Planning and problem solving
Decision making based on reward and penalty
Self-regulation
FRONTAL LOBE FUNCTIONS (1)
 4 Functional Domains
1.
Executive
2.
Behavioral/Emotional Self-regulatory
3.
Energization regulating
4.
Metacognitive
FRONTAL LOBE FUNCTIONS (2)
 EFs mediated by frontally guided, distributed
networks involving prefrontal subregions, posterior
cortex, and subcorticalstructures (e.g., basal ganglia,
ventral striatum)
 1 – Executive Cognitive Functions
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Anatomy – lateral prefrontal cortex (LPFC)
Function Overview – control and direction of lower
level/automatic functions

Planning, monitoring, activating, switching, inhibiting
 2 – Behavioral/emotional self-regulatory functions
 Anatomy – ventral (medial) prefrontal cortex (VPFC)
 Function Overview – emotional responsiveness, reward
processing, behavioral self-regulation
FRONTAL LOBE FUNCTIONS (3)
 3 – Energization regulating functions
 Anatomy – superior medial frontal lobes, anterior cingulate;
frontal cortical-subcortical circuits
 Function Overview – capacity to generate and maintain
actions important for adequate performance of other
functions
Extreme case – abulia, or severe apathy
 Most common presentation – slowed reaction time, slowed
processing speed

 4 – Metacognitive functions
 Anatomy – frontal pole (BA 10) (right hemisphere bias?);
connections to other regions
 Function Overview – integrative aspects of personality, social
cognition, consciousness, theory of mind, humor
TBI and Executive Function
 TBI “arguably the most important single cause of
frontal lobe dysfunction” (p 469)
 The cognitive and behavioral consequences of TBI
are the most enduring and have most impact (more
than physical).

“The chronic disability of TBI is accentuated by its tendency to
take place during early adulthood, affecting behavior for
decades.” (p 469)
 Can occur with both penetrating and non-
penetrating TBI
Treatment of Frontal Lobe Dysfunction (1)
 1 - Executive/cognitive
 Problem solving and planning

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Problem-solving training (PST)
Working memory training
 2 - Behavioral/Emotional Self-regulatory
 Treatment targeting “goal neglect” (to bridge gap
between intention and action)
 Goal management training (GMT)
 External aids/cues
Treatment of Frontal Lobe Dysfunction (2)
 3 - Energization regulating
 Pharmacologic intervention

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Dopamine agonists, serotonin agonists
External aids/cues
 4 - Metacognitive
 Deficit awareness
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Awareness Intervention Program (AIP)
Error awareness and self-monitoring

Self-monitoring training (SMT)
EBRs: EXECUTIVE FUNCTION (1)
 Practice Standard
 Metacognitive strategy training (self-monitoring, selfregulation) for executive functioning and emotional selfregulation

As a component of attention, neglect, and/or memory treatment
 Practice Guideline
 Problem-solving training (everyday situations, functional
activities)

Postacute
 Practice Options
 Group-based intervention for executive function and problemsolving
EBRs: EXECUTIVE FUNCTION (2)
 Previous standards, guidelines, options were for
adults only
 There are no established cognitive interventions for
children with TBI

Generally, approaches used for LD and ADHD are employed
 Assessment and treatment of EFs in children is
especially complicated, because of the diversity of
EFs as well as the differences in developmental
trajectories for the different EF processes

Gray and white matter volume, lateralization, and distribution of
cognitive control changes with age; “notable shortage” of
neuroimaging studies for ped TBI
TBI and ATTENTION
Attention (1)
 Multidimensional
 Sensory selective attentional system
Parieto-temporo-occipital area
 Orienting, engaging, and disengaging attention and object
recognition
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Arousal, sustained attention and vigilance system
Midbrain reticular activating system and limbic structures
 Arousal, sustained attention, vigilance, mood, motivation, salience
of stimuli, readiness to respond

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Anterior system for selection and control of responses
Frontal lobes, anterior cingulate gyrus, basal ganglia, thalamus
 Intentional control and use of strategies for manipulating
information, active switching and inhibition

Attention (2)
LEVELS AND TYPES
FUNCTION
ASSESSMENT
AROUSAL
State of consciousness;
primitive wakefulness
Gross motor response to
sensory stimulation
AWARENESS
Assumes arousal; from
stupor to clear perception of
surroundings
Answer questions
SELECTIVE ATTN
Focus; resistance to
Two stimuli or tasks;
distraction; managing limited response to one
resources by selection
SUSTAINED ATTN
Vigilance or concentration;
maintaining focus on one
stimulus for a period of time
DIVIDED ATTN
Allocating limited resources
Two stimuli or tasks;
to multiple processes or tasks response to both (dual
task paradigms)
A series of stimuli and
response to one
Common terms and categorization in testing and treatment
Attention (3)
 TBI => diffuse and bilateral injury to many regions
including frontal, temporal, meso-limbic, and midbrain
reticular formation areas
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These areas are involved in attention
One of most common cognitive complaints post-TBI
Commonly assessed via:
Digit span (e.g., subtest of Wechsler Memory Scale; WMS)
 WAIS - Digit symbol coding and symbol digit modalities tests
 SART – Sustained Attention and Response Task
 TMT – Trail Making Test
 BTA – Brief Test of Attention
 TEA – Test of Everyday Attention
 Attention Questionnaire

Attention (4)
 Sensory selective attentional system

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Rarely damaged relative to other systems
If damaged, => object recognition difficulty, unilateral spatial neglect
 Arousal, sustained attention and vigilance system

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Commonly damaged
If damaged, => decreased perceptual sensitivity/decreased vigilance
 Anterior system for selection and control of responses

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Commonly damaged
If damaged, => slower to perform selective and divided attention
tasks, impaired speed of information processing (increased RT),
distractible,
Attention (5)
 EBRs
 Practice Standards
 Remediation of attention during postacute rehabilitation
 Should include direct attention training
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Contextualized
Should include metacognitive training to promote
development of compensatory strategies and foster
generalization to real-world tasks.
 Practice Option
 Computer-based interventions as an adjunct to clinicianguided treatment of attention deficits
Metacognitive techniques:
Goal definition => Performance
predictions => planned strategy
use => self-evaluation => selfreflection
Role reversal, audio-visual
feedback
Tasks such as food preparation,
laundry, driving, work duties
TBI and MEMORY
MEMORY (1)
 Working (and short-term) memory - involved in the
acquisition of new information and the activation of
old or stored information whenever it is needed for
a task; make contact with the knowledge in LTM
 Long-term memory (LTM)

Retrospective memory – memory for past events and
experiences and for information acquired in the past
Declarative memory
 Episodic memory
 Semantic memory
 Procedural memory

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Prospective memory – ability to remember to do things at
specific points in time
MEMORY (2)
 TBI => diffuse and bilateral injury to many regions
including temporal and basal-frontal regions
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These areas are involved in memory
Difficult to separate from attention
Commonly assessed via:
WMS - Wechsler Memory Scale
 Digit/letter/word span for immediate retention
 AMI – Autobiographical Memory Interview
 GOAT – Galveston Orientation and Amnesia Test
 RBMT – Rivermead Behavioral Memory Test
 CAMPROMPT – Cambridge Prospective Memory Test
 Corsi Block-tapping Test
 Memory for Designs Test (of Stanford-Binet Intelligence Scale)

MEMORY (3)
 EBRs
 Practice Standard

Memory strategy training (internalized strategies [e.g., visual
imagery], external memory compensations [e.g., notebooks])

Mild memory impairment
 Practice Guideline

Memory strategy training (with external compensations) with direct
application to functional activities

Severe memory impairment
 Practice Options

Errorless learning for specific skills or knowledge
Severe memory impairment
 Evidence of limited transfer/generalization

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Group-based intervention
TREATING THE WHOLE
PATIENT
EBRs: COMPREHENSIVE-HOLISTIC
NEUROPSYCHOLOGIC REHABILITATION
 Practice Standard
 C-HNR to reduce cognitive and functional disability
Postacute
 Moderate to severe TBI

 Practice Options
 Integrated cognitive + interpersonal + comprehensive
neuropsychological rehabilitation
 Group-based interventions
COMPREHENSIVE-HOLISTIC
NEUROPSYCHOLOGIC REHABILITATION (1)
 Cicerone et al., 2004, 2008
 Outpatient, postacute
 Comprehensive-Holistic = 16 weeks (15-20 hours/week)
 Core treatment
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Cognitive group treatment
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Individual and/or group psychotherapy, family support and involvement, therapeutic
work trials, ADLs, assessment of progress, observing videotapes of
communication/interaction, feedback to self and others, etc.
Functional activities with emphasis on executive functioning, metacognitive functioning,
interpersonal group processes
Individual cognitive remediation (patient involved in goal setting and content of
activities)
Group communication treatment – communication, interpersonal communication style,
perspective taking, social behavior, pragmatic language skills
 Standard = 16 weeks (12-24 hours/week)
 Primarily individual, separate sessions of physical, occupational, speech, and
neuropsychologic therapy
 Also recreational, vocational, and/or educational therapy/intervention, psychologic
counseling
COMPREHENSIVE-HOLISTIC
NEUROPSYCHOLOGIC REHABILITATION (2)
 Comprehensive-Holistic => greater improvements
when compared to standard neurorehabiltation
program of similar intensity/duration

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Twice the magnitude of treatment effects observed in
community integration
Also => greater improvements in neuropsychologic
functioning
Improvement on complex attention and executive functioning
tasks directly related to community integration
Pediatric TBI and Academic Re-entry
Community Integration and Vocational
Rehabilitation
TBI and disorders of mood, affect, and
motivation
TBI and psychosocial factors