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Treatment efficacy: Cognitive-communicative


disorders resulting from traumatic brain injury
in adults

Article in Journal of speech and hearing research November 1996


DOI: 10.1044/jshr.3905.s5 Source: PubMed

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Journalof Speech and Hearing Research, Volume 39, S5-S 17, October 1996

Treatment Efficacy: Cognitive-


Communicative Disorders Resulting
From Traumatic Brain Injury in Adults

Carl A. Coelho
Southern Connecticut State University
New Haven

Frank DeRuyter
Duke University Medical Center Traumatic brain injuries (TBI) may result in a broad array of cognitive-communicative impair-
Durham, NC ments. Cognitive-communicative impairments are the result of deficits inlinguistic and nonlinguistic
cognitive functions. The speech-language pathologist functions as a member of the multidisciplinary
Margo Stein* team of professionals that collaboratively assess and treat individuals with TBI. The role of the
Health Care Consultant speech-language pathologist includes assessment of all aspects of communication, as well as
St. Louis, MO the communicative implications of cognitive deficits, and swallowing; treatment planning and pro-
gramming, as determined by the individual's stage of recovery; client and family training/counsel-
ing; and interdisciplinary consultation. The effectiveness of speech and language intervention for
specific cognitive deficits (e.g., attention, memory, executive functions) as well as general issues
of social-skills training and early intervention are illustrated by scientific and clinical evidence from
group-treatment and single-subject studies as well as case studies.

KEY WORDS: traumatic brain injury, cognitive rehabilitation, communication disorders,


intervention studies, treatment outcome

There is both scientific and clinical questions; both methodologies are in-
evidence that individuals with cognitive- cluded in this analysis.
communicative disorders resulting from Other sources of information, includ-
traumatic brain injury (TBI) benefit from ing program evaluation data and case
the services of speech-language patholo- studies, lend support to experimental
gists. This evidence is documented in findings of treatment efficacy. Thus, such
experimental research, program evalu- information is included in this review. Al-
ation data, and case studies. The pur- though program evaluation data cannot
pose of this paper is to summarize the answer questions about causal relation-
evidence pertaining to treatment efficacy ships between the process and outcome
for cognitive-communicative disorders of treatment, they can document trends
secondary to TBI in adults. intreatment for large patient/client popu-
Olswang (1990) has pointed out that lations, often defined by functional out-
treatment efficacy is a broad term that comes. Finally, case studies offer more
can address several questions related to individualized and patient/client-oriented
treatment effectiveness (i.e., Does treat- accounts of treatment benefit.
ment work?), treatment efficiency (i.e.,
Does one treatment work better than
another?), and treatment effects (i.e., In
Definition of Cognitive-
what ways does treatment alter behav- Communicative Disorders
ior?). Treatment efficacy studies have Communication is a process by which
used either group or single-subject ex- information is exchanged (Davis, 1983).
perimental designs to answer these The ability to communicate requires a

*Currently affiliated with the American Speech-Language-Hearing Association

1996, American Speech-Language-Hearing Association S5 0022-4685/96/3905.00S5

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S6 Journalof Speech and Hearing Research 39 S5-S17 October 1996

complex interaction between cognition Although each type of injury may occur Because no two TBI cases are the same,
and language (Adamovich, 1991). Cog- in any region of the brain and result in each injury yields a diverse constellation
nitive skills include such processes as very different patterns of deficits, certain of cognitive-communicative, physical,
attention, memory, reasoning, problem regions of the brain are highly vulnerable and psychosocial deficits. The degree to
solving, and executive functioning (i.e., in closed head injury. For example, the which these deficits impede the perfor-
self-awareness and goal setting, plan- prefrontal region (front of the brain just mance of everyday activities depends in
ning, self-directing/initiating, self-inhibit- behind the forehead) and the limbic sys- part on the nature of the activities in
ing, self-monitoring, self-evaluation, flex- tem (located deep within the center of which a particular individual was en-
ible thinking). Language skills involve the brain), as well as the connections gaged before the injury. The impact of
transmission of spoken, written, or non- between the limbic system and the pre- TBI is perhaps best understood when
verbal messages (e.g., gestures, facial frontal region, are most vulnerable (Levin considered within the context of the
expression) and reception of auditory, & Kraus, 1994). World Health Organization's proposed
printed, or nonverbal messages. Difficulty Kraus (1993) estimated that 500,000 classifications of impairment, disability,
or failure with any of these expressive- individuals sustain head injury each year and handicap (World Health Organiza-
receptive abilities or with any aspect of (200 per 100,000 population). Of this tion, 1987). Impairment is defined as an
cognition may result in a breakdown in number, 200,000 die, 50,000 to 100,000 abnormality in physical or mental func-
communication and thus the inefficient survive with significant impairments pre- tion-for example, cognitive disruption
exchange of information. Traumatic brain venting independent living, and more such as decreased attention, which typi-
injury may result in cognitive-communi- than 200,000 suffer continuing sequelae cally results from TBI. Disability refers to
cative impairments. Cognitive-communi- that interfere with daily living skills a limitation in performance of an activity
cative impairments are those impair- (Gualtieri, 1988; Jennett, Snoek, Bond, because of an impairment; for example,
ments of communication related to & Brooks, 1981; Kalsbeek, McLauren, difficulty sustaining attention would influ-
impairments of linguistic (e.g., syntax, Harris, & Miller, 1981; Kraus, 1978). Of ence the ability to read and follow instruc-
semantics, metalinguistic skills) as well the individuals who sustain TBI, nearly tions. Handicap is a loss of social role
as nonlinguistic cognitive functions (e.g., twice as many males as females are in- function because of disability. Perhaps
attention, perception, and memory; jured. The risk of TBI is higher among the most disabling and handicapping ef-
ASHA, 1987,1990). males 15 to 24 years of age and the eld- fect of TBI is a reduced capacity to pur-
erly (over 75 years). Inthe United States, sue preinjury interests and daily activi-
trauma is the third leading cause of death ties at the same functional level. Such
Incidence and Prevalence among individuals under the age of 35 disability exists along a broad continuum
Data (National Head Injury Foundation, 1983). that can range from requiring additional
Traumatic brain injuries result from More than two thirds of all head inju- time to complete tasks to near total de-
some form of trauma to the head. Such ries are classified as mild. Definitions of pendence on others for all basic needs.
injuries are classified as either penetrat- mild TBI vary; consequently, it has been Symptoms following mild TBI are quite
ing (e.g., a gunshot wound) or closed difficult to compare outcomes for such variable and may include difficulty con-
head injuries (e.g., resulting from sudden individuals from different treatment cen- centrating under distracting conditions or
acceleration/deceleration forces, such as ters. The American Congress of Reha- problems managing tasks involving mul-
when a head strikes the dashboard of a bilitation Medicine (1993) has defined tiple demands. Areas commonly dis-
car) depending on whether or not the mild TBI as traumatically induced physi- rupted are attention, memory, and execu-
meninges (the protective membranes ological disruption of brain function mani- tive functioning. Mild TBI may also result
that cover both the brain and the spinal fested by at least one of the following: in word-finding difficulties, decreased
cord) remain intact. A broader definition (a) any period of loss of consciousness; motivation, anxiety, depression, and irri-
of closed head injury also includes inju- (b) any loss of memory for events imme- tability (Levin, Eisenberg, & Benton,
ries in which the meninges remain intact diately before or after the injury; (c) any 1989; Sohlberg & Mateer, 1989a). These
but are disrupted-as seen, for example, alteration in mental state at time of injury deficits are present in spite of normal find-
incases of shaken impact syndrome (i.e., (dazed, confused, disoriented); or (d) ings on conventional diagnostic proce-
child abuse in which a child is shaken focal neurological deficits (may or may dures such as computerized tomography
violently; Levin, Goldstein, Williams, & not be transient) that result in loss of con- and magnetic resonance imaging. Long-
Eisenberg, 1991). There are distinct dif- sciousness for 30 minutes or less, an term follow-up of patients with mild head
ferences between penetrating and closed initial Glascow Coma Scale score of 13- injury often reveals loss of jobs, divorce,
head injuries in terms of type of deficits 15, and posttraumatic amnesia not substance abuse, and generally disorga-
and recovery, the discussion of which is greater than 24 hours. nized lives.
beyond the scope of this article (see Alexander, Benson, and Stuss (1989)
Grafman & Salazar, 1987, for a review). note that in individuals with prefrontal
Effects of Cognitive- injury, linguistic skills are typically intact;
Penetrating head injuries usually result Communicative Disorders
in focal lesions to specific areas of the however, they may show the following
brain. Closed head injury may result in
on Daily Life Activities deficits: (a)disorganized or impoverished
focal lesions, diffuse axonal injury The effects of TBI on the survivor and discourse (receptively and expressively);
(stretching, tearing, and shearing of family are dependent, in large measure, (b) awkward or inappropriate social in-
nerve fibers), or a combination of both. on the nature and severity of the injury. teraction (i.e., difficulty with pragmatic

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Coelho et al.: Treatment Efficacy in Cognitive-Communicative Disorders S7

dimensions of language, including diffi- native communication, as well as swal- the best techniques for interacting with
culty interpreting social cues); (c) difficulty lowing. Upon completion of this assess- the patient/client. In later stages of re-
with abstract forms of language (e.g., ment the findings are interpreted, and a covery, traditional cognitive rehabilitation
abstract concepts, figures of speech, prognosis and treatment recommenda- takes place. Individual and/or group treat-
irony, sarcasm); (d) difficulty with flexibil- tions are formulated. Treatment planning ment may be supplemented by com-
ity in linguistic processing (e.g., ambigu- includes collaboration with educational puter-assisted treatment. To facilitate
ity); or (e)difficulty with speed of process- and vocational specialists to enable the carryover of treatment objectives to
ing. Injuries to the limbic system as well TBI individual to succeed educationally nonclinical environments, contextu-
as the connections between the prefontal and/or vocationally. alization of treatment activities takes
and the limbic structures are also char- Speech-language pathologists are place as soon as it is feasible. For ex-
acterized by generally intact linguistic responsible for the establishment of treat- ample, early return to work with a job
skills, but are associated with inefficient ment programs aimed at decreasing the coach or educational intervention with an
learning of new information (including lin- effects of impairments in all aspects of emphasis on inclusionary placement and
guistic information) and reduced control speech, language, cognitive-communi- support in that setting are methods to fa-
over emotional responses. cative functioning, and swallowing. The cilitate carry-over. Family or significant
Jacobs (1988) surveyed the families treatment plan includes long- and short- other training/counseling, as well as in-
of 142 survivors of severe TBI regarding term objectives (reviewed on a regular terdisciplinary consultation and dismissal/
whether or not the survivor was indepen- basis); information regarding frequency, discharge planning, also are ongoing.
dent in a variety of behavioral skills. The estimated duration, and type of service;
skill areas involved a range of abilities and follow-up or referral to other profes-
(e.g., reading, writing, telling time, con- sionals as necessary. In addition, Definition of Cognitive
centration, remembering, and orienta- speech-language pathologists help to Rehabilitation
tion) and a range of complexity (e.g., for identify effective and functional supports Cognitive rehabilitation refers to a
reading: reads and recognizes directional to enable cognitively disabled individu- treatment regimen aimed at increasing
signs or reads books). Results indicated als to be as independent and successful functional abilities in everyday life by
that TBI had a significant impact on the as possible. Such supports may include improving an individual's capacity to pro-
survivors' ability to independently per- cognitive prosthetic devices (e.g., cess and interpret incoming information.
form a variety of daily living skills. memory logs), adjustment of work expec- Two approaches to cognitive rehabilita-
The impact of TBI on the family may tations (by co-workers and employer), tion-restorative and compensatory-
be equally devastating. Jacobs (1988) changes in the work/classroom environ- have been described. The restorative
noted that although many survivors of ment (e.g., allowing the individual to work approach is based on the notion that
severe TBI live with their families, they where distractions are minimal), modifi- neuronal growth, and thus improvement
do not work or attend school and are cation of teaching procedures to be con- in function, is associated with repetitive
dependent upon others for accomplish- sistent with the individual's cognitive exercise of neuronal circuits. Incontrast,
ing daily skills, both inside and outside strengths and weaknesses (e.g., elimi- the compensatory approach operates on
the home. nation of time constraints, as in untimed the assumption that certain functions
tests). Throughout the treatment planning cannot be recovered; therefore, the de-
Role of the Speech-Language process the issue of context must be velopment of strategies to circumvent
Pathologist carefully considered. Context refers to impaired functions is the primary goal.
both the content of what a particular in- This conception of cognitive rehabilitation
The speech-language pathologist is dividual needs as well as the setting or suggests that "restoration" and "compen-
a member of the team of rehabilitation physical environment that the individual sation" are distinct phases of rehabilita-
professionals that collaboratively as- needs in order to function optimally. tion such that compensatory strategies
sesses and treats individuals who have Decontextualized treatment activities that are not implemented until restorative ex-
sustained TBI (see Ylvisaker, 1994). take place in artificial environments (set- ercises have failed. However, it has been
Speech-language pathologists assume tings that are different from those the in- observed that helping TBI individuals to
primary responsibility for the assessment dividual will encounter in the real world) become increasingly aware of their cog-
of all aspects of communication: hear- and that involve tasks the individual will nitive needs and to be strategic in ap-
ing screening (with referral for compre- never be called upon to perform may not proaching cognitively demanding tasks
hensive audiologic assessment as constitute effective intervention (Klonoff, (i.e., using a "compensatory" approach)
needed), spoken language (comprehen- O'Brien, & Prigatano, 1989; Lawson & is actually restorative; that is, this re-
sion & production), written language Rice, 1989; Singley & Anderson, 1989). stores the strategic, deliberate aspect of
(reading & writing), cognitive-communi- Treatment programs vary depending cognitive processing. Therefore, it is in-
cative functioning (i.e., exploring the on the stage of recovery (Adamovich, appropriate to contrast "restorative" and
communicative implications of impair- Henderson, & Auerbach, 1985). In the "compensatory" as though they were not
ments in such areas as orientation, at- early stages of recovery the speech-lan- overlapping approaches. Rather it has
tention, memory, reasoning, problem guage pathologist directs efforts at elic- been suggested that these approaches
solving, executive functions), speech pro- iting and sustaining responses by the should occur simultaneously in rehabili-
duction (articulation, fluency, phonation, patient/client. All sensory modalities may tation (M. Ylvisaker, personal communi-
and resonance), augmentative and alter- be used, and the clinician must identify cation, April 1995).

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S8 Journal of Speech and Hearing Research 39 S5-S17 October 1996

Evidence of the Benefits of program used a general stimulation ap- Questad, 1983; Molloy, Rand, & Brown
Treatment proach and the other a structured as cited in Benedict, 1989; Ryan & Ruff,
remediation approach focused on atten- 1988). Details of these studies and oth-
The literature on the efficacy of cog- tion, spatial integration, and problem ers appear in Table 2.
nitive rehabilitation has focused either
solving. Both treatments involved group Although the findings of these reports
on the effects of general TBI rehabili- therapy. Following treatment, both groups are encouraging, a problem common to
tation programs (in which the services of subjects showed significant improve- many memory-retraining approaches
of speech-language pathologists are ments in cognitive function, suggesting and to cognitive rehabilitation programs
one component) or on specific interven- that treatment ina structured setting, with in general is that of generalization. Most
tions for discrete deficits (e.g., atten-
a trained professional and psychosocial authors agree that after the treatment
tion and memory). Findings from sev- group support, has positive effects on situation is removed, spontaneous imple-
eral studies concerned with both are cognitive functioning independent of the mentation of the learned skill is minimal
summarized below. particular method of treatment. and many of the skills taught do not im-
prove functional, everyday memory
General RehabilitationPrograms (Lawson & Rice, 1989; O'Connor &
Attention
Cermack, 1987; Parente & Parente-
Rehabilitation programs consisting of Several studies have reported improved Anderson, 1989; Schacter & Glisky,
general interventions targeting cognitive attention following treatment involving au- 1986). However, there are case studies
abilities and community-oriented groups ditory and/or visual modules (Ben-Yishay, of memory interventions with TBI indi-
for facilitating appropriate social skills Piasetsky, & Rattock, 1987) and verbal viduals in which successful generaliza-
have resulted in improved functioning in repetition (Malec, 1984). Success also has tion and transfer of trained tasks has
subjects with TBI. That is, statistically sig- been reported with computer-assisted at- been noted-for example, see Lawson
nificant improvements on standardized tention retraining (Ruff et al., 1994; and Rice (1989) and Sohlberg and
neuropsychological tests have been Sohlberg & Mateer, 1987). However, some Mateer's (1989b) report on the use a
noted following treatment (Prigatano et computer-assisted retraining programs memory book. Recently, also reported to
al., 1984). For example, the effectiveness have led to significant gains in attentional be successful is a computer-based mul-
of cognitive retraining for such abilities performance, without generalization of timedia program for memory retraining
as attention, memory, and problem- solv- treatment effects (Nieman, Ruff, & Baser, (Ruff et al., 1994).
ing skills was investigated by Ruff, Baser, 1990). Finally, performance feedback
Johnson, and Marshall (1989). Results (Webster, McCaffrey, & Scott, 1986) and Executive Functions
showed improvements for both a control reinforcement (Wood, 1986) also have
group of subjects who received training been shown to improve certain aspects of Difficulties with executive functions
in such areas as health and art and a some TBI subjects' attention skills. See are common afterTBI and are frequently
group of subjects who received cognitive Table 1 for a summary of studies focused associated with damage to the frontal
retraining. However, subjects who re- on improving attention skills. and prefrontal cortex (Sohlberg, Mateer,
ceived memory training showed improve- & Stuss, 1993). According to Lezak
ments beyond that of the control group. (1982), executive functions comprise
Memory
Harrington and Levandowski (1987) also those mental capacities necessary for
showed statistically significant improve- Some degree of memory dysfunction formulating goals, planning how to
ment on posttest Luria-Nebraska Neuro- is a consistent finding in most individu- achieve them, and carrying out the plans
psychological Battery scores after com- als following TBI. Consequently, numer- effectively. Ylvisaker and Szekeres
munity-oriented group rehabilitation. ous studies have investigated the pos- (1989) note that following severe trau-
Improvements appeared on a variety of sible underlying nature of memory matic brain injury most individuals dem-
neuropsychological functions, including dysfunction in this population. TBI pa- onstrate communicative deficits directly
memory. tients/clients may have difficulty retriev- attributable to disruption of executive
Somewhat mixed findings were re- ing information because of problems with functions. They list a number of dimen-
ported for a group of TBI individuals en- the encoding stage of memory that are sions of executive functioning in which
rolled in a post-acute rehabilitation pro- due to a decreased ability to generate this dysfunction may occur, including (a)
gram (Mills, Nesbeda, Katz, & Alexander, semantic associations (Levin & Goldstein, self-awareness and goal setting, (b)
1992). Although cognitive measures 1986) and visual imagery (Richardson, planning, (c) self-direction and initiation,
were not affected by treatment, there 1984). Therefore, a variety of mnemonic (d) self-inhibition, (e) self-evaluation,
were significant improvements on vari- training strategies have been developed and (f) flexible problem solving. It has
ous functional measures reflecting im- in an effort to enhance these associations been suggested that problems with ex-
provements inhome, community, leisure, and images (Crovitz, 1979; Crovitz, ecutive functions, more than any other
and vocational activities. Follow-up at 6, Harvey, & Horn, 1979; Gianutsos & cognitive ability, determine the extent of
12, and 18 months demonstrated main- Gianutsos, 1979; Wilson, 1987). Several social and vocational recovery follow-
tenance of treatment effects. Similarly, studies also have investigated the effect ing TBI (Sohlberg & Mateer, 1989a).
Ruff and Niemann (1990) compared two of simultaneous practice of multiple strat- Self-monitoring procedures (Sohlberg,
types of cognitive rehabilitation on egies (Daniel, Webster, & Scott, 1986; Sprunk, & Metzelaar, 1988) and verbal
neuropsychological performance. One Fussey & Tyerman, 1985; Malec & and visual feedback (Burke, Zencius, &

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Coelho et al.: Treatment Efficacy inCognitive-Communicative Disorders S9

TABLE 1. Summary of a sampling of treatment efficacy studies for deficits of attention resulting from TBI.

Study N Treatment focus Improvements/findings reported

Ben-Yishay, Piasetky, & 11 Orientation Remedial Module, five tasks Subjects progressed from impaired to
Rattock (1987) involving reception of visual and/or auditory normal range for all five tasks after training
stimuli and elicitation of simple visuomotor and at 6-month follow-up
responses
Malec (1984) 1 Practice with verbal repetition task Gains inselective attention noted during
conversation
Sohlberg & Mateer (1987) 4 Hierarchy of computer tasks for focused, Processing speed and vigilance
sustained, selective, alternating, and divided
attention
Ruff, Mahaffey, Engel, 15 Selected tasks tailored to individual's needs Performance on computer tasks, psycho-
Farrow, Cox, & Karzmark using THINKable (computer-based metric measures, and patient and observer
(1994) multimedia program developed by IBM) in ratings of everyday attention and memory
attention and memory behaviors
Niemann, Ruff, & Baser 29 Computer-assisted attention retraining Attention performance, but no generaliza-
(1990) tion of treatment effects (perhaps due to
frontal lobe dysfunction)
Webster, McCaffrey, & Scott 2 Reaction time practice with performance Reaction time performance
(1986) feedback
2
Wood (1986) Token reinforcement for selective attention Selective attention enhanced
Wood (1986) 4 Reinforced practice of attention tasks Gains noted on training tasks; no change
on other measures of attention

Weslowski, 1991) have been used intrain- have described a memory remediation abilities are vulnerable to disruption fol-
ing to improve certain aspects of execu- program consisting of both compensa- lowing TBI.
tive functions (e.g., verbal initiation, re- tory and executive training skills. The Several studies documenting the ef-
sponse acknowledgment) with reported executive strategy training was designed fectiveness of social skills training with
success (see Table 3 for summaries of to give individuals practice in the plan- TBI individuals have appeared in the lit-
these and other studies). Other rehabili- ning and analysis of task demands, in erature. For example, studies have de-
tation efforts aimed at improving execu- selecting a strategy, in monitoring the scribed the use of videotape feedback
tive functions in individuals with TBI re- course of an activity, and in evaluating (Brotherton, Thomas, Wisotek, & Milan,
semble approaches to metacognitive the outcome of the activity. This practice 1988; Helffenstein & Wechsler, 1982),
functioning that have been studied for led to very encouraging outcomes, which conversational skills training (Gajar,
many years in the field of educational suggest that the functional memory skills Schloss, Schloss, & Thompson, 1984;
psychology. That literature contains nu- of certain TBI individuals can be im- Schloss, Thompson, Gajar, & Schloss,
merous positive reports on the efffective- proved with treatment. 1985), treatments targeting the reduction
ness of this type of intervention with of inappropriate speech (Burke & Lewis,
learning-disabled children and adoles- 1986; Giles, Fussey, & Burgess, 1988;
cents. Caution certainly needs to be ex- Social Skills Training
Lewis, Nelson, Nelson, & Reusink, 1988;
ercised inmaking cross-population infer- Social skills include a variety of abili- Zencius, Wesolowski, & Burke, 1990),
ences; however, application of this ties (e.g., conversing, sharing, cooper- pragmatics (Ehrlich & Sipes, 1985), and
knowledge base to TBI rehabilitation has ating, greeting others) that enable an in- general social skills (Braunling-McMorrow,
been discussed by Pressley (1993) and dividual to interact effectively with peers Lloyd, & Fralish, 1986). These studies are
Meichenbaum (1993). The successful and with others at home, in school, on summarized in Table 4.
incorporation of metacognitive processes the job, and in other environments
into treatment procedures for TBI pa- (Ylvisaker, Szekeres, Haarbauer-Krupa,
tients with decreased planning ability and Urbanczyk, & Feeney, 1992). An indi- Community Re-Entry
poor self-control and self-monitoring vidual who is "socially skilled" (a) has Sustained community re-entry at the
skills also has been reported by Cicerone knowledge of social rules, roles, and highest level of productivity, indepen-
and Giacino (1992) and Cicerone and routines; (b) accurately perceives and dence, and social adaptation for indi-
Wood (1987). interprets social cues; and (c) can regu- vidual patients/clients is the desired goal
Finally, other authors (Freeman, late behavior (M. Ylvisaker, personal of TBI rehabilitation (Malkmus, 1989).
Mittenberg, Dicowden, & Bat-Ami, 1992) communication, April 1995). These Concerns have been expressed about

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S10 Journal of Speech and HearingResearch 39 S5-S 7 October 1996

TABLE 2. Summary of a sampling of treatment efficacy studies for memory deficits resulting from TBI.

Study N Treatment focus Improvements/findings reported

Crovitz, Harvey, &Horn 1 Mnemonic training strategies to improve Ability to link stimulus words to visual
(1979) ability to generate semantic associations associations
Crovitz (1979) 1 Mnemonic training Verbal recall
Gianutsos &Gianutsos 1 Mnemonic training Word list recall
(1979)

Wilson (1987) 8 PQRST strategy (preview material, ask Recall of written paragraphs was superior
questions, read to answer questions, study with PQRST versus simple rehearsal for
information, test for recall) immediate and 30-minute recall conditions

Wilson (1987) 36 Utility of three types visual imagery All patients able to use clinician-supplied
strategies: rehearsal, clinician-generated, cues, but only mildly imparied patients
and patient generated could generate their own imagery cues
Fussey & Tyerman (1985) 4 Simultaneous practice of multiple mnemonic No improvement in memory noted
strategies: visual imagery and semantic
elaboration

Molloy, Rand, & Brown (as 1 Visual imagery and breaking down target Increased recall scores
cited in Benedict, 1989) visual stimulus into component parts

Malec & Questad (1983) 1 Visual imagery and semantic story Gains on Wechsler Logical Memory; no
elaboration change in word association

Daniel, Webster, & Scott 1 Visual imagery and self-instruction Increased scores on paired associate recall
(1986)
Ryan & Ruff (1988) 10 Visual imagery and group intervention No gains in Wechsler Logical Memory;
other improvements dependent on degree
of memory impairment

Ruff, Mahaffey, Engel, 15 Selected tasks tailored to patient's needs Performance on computer tasks, psycho-
Farrow, Cox, & Karzmark using THINKable (computer-based metric measures, and patient and oberver
(1994) multimedia program developed by IBM) in ratings of everyday attention and memory
attention and memory behaviors

Sohlberg & Mateer (1989b) 1 Compensatory memory book Client learned to use system independently,
returned to work, lived in apartment with
minimal assistance despite deficits in
memory and new learning

Lawson & Rice (1989) 1 Executive strategy training to improve Improved recall performance, maintenance
spontaneous use of verbal recall strategy of strategy knowledge, and ability to
WSTC: (What am I supposed to be doing? implement novel strategies
Select a strategy. Try a strategy. Check the
strategy.)

the maintenance and generalization of remediation involves activities of high tent with the issue of the context of in-
treatment gains demonstrated inclinical interest to the individual (Huber & tervention discussed above. Recently,
settings. Such concerns have risen from Edelberg, 1993; Kneipp, 1991; Seaman, numerous case reports of treatment in-
research indicating that individuals with Roberts, Gilewski, & Nagai, 1993). Fur- tended to enhance daily living, educa-
TBI often demonstrate chronic memory ther, such treatment enables clinicians tional, and vocational activities provided
problems; and those with frontal lobe in- to identify skills that appear to be intact by professionals who travel to the TBI
juries, in particular, have extreme diffi- or functional in the sterile clinical set- individual's home, school, or job have
culty spontaneously executing trained ting, but are actually nonfunctional in a cited positive results with regard to re-
strategies or techniques. home or work environment (Starch & turn to school (Blosser & DePompei,
Functional gains are most easily Falltrick, 1990). Therefore, community- 1989; DePompei, & Blosser, 1987) or
achieved when cognitive remediation based intervention enables clinicians to gainful employment (Brantner, 1992;
is carried out in the patient's/client's establish meaningful goals and to evalu- Kneipp, 1991; Story, 1991; Wehman,
home and community and when such ate progress. This is certainly consis- 1991; Wehman et al., 1993).

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Coelho et al.: Treatment Efficacy in Cognitive-CommunicativeDisorders S11

TABLE 3. Summary of a sampling of treatment efficacy studies for deficits of executive functions resulting from TBI.

Study N Treatment focus Improvements/findings reported

Sholberg, Sprunk, & 1 Self-monitoring procedure for two aspects of Increase over baseline intarget communi-
Metzelaar (1988) executive functions (verbal initiations and cation behaviors during use of external
response acknowledgment) cues
Burke, Zencius, & Weslowski 6 Verbal and visual feedback and various Upon removal of checklists and feedback
(1991) checklists for improving social behaviors, trained behaviors were maintained
problem solving, and initiation
Cicerone & Wood (1987) 1 Three-stage training procedure for verbal Gains noted post-training as well as
mediation followed by generalization training generalization
with application to real-life problems
(decreased planning ability and poor self-
control)
Cicerone & Giacino (1992) 6 Self-instructional technique using Tower of Improved performance
London puzzle as training task
Cicerone & Giacino (1992) 1 Error-monitoring involving self-recording of Improved self-monitoring ability
errors and analysis of performance on
Tower of London puzzle
von Cramon & Matthes-von 1 Generation of alternatives to a problem, Successful use of technique by an
Cramon (1994) analysis of information, practice processing individual with severe frontal lobe dysfunc-
multiple bits of information simultaneously, tion to the point that he was able to secure
and drawing inferences supported employment
Freeman, Mittenberg, 6 Compensatory and executive training Significantly improved paragraph recall
Dicowden, & Bat-Ami (1992)

Individual Differences Early Intervention to study the efficacy of cognitive reha-


bilitation. Applications of single-subject
The benefits of early aggressive reha-
When the effectiveness of cognitive designs to cognitive rehabilitation have
bilitation (including speech-language pa-
rehabilitation is evaluated, individual dif- been described (Franzen & Harris, 1993;
thology services) during acute hospitaliza-
ferences among TBI patients/clients must Gianutsos & Gianutsos, 1987; Wilson,
tion following TBI has been quantified by
be considered. For example, Ryan and 1982) and reported by a number of in-
Mackay and colleagues (MacKay,
Ruff (1988) noted that attention and vestigators (Gajar et al., 1984; Schloss
Berstein, Chapman, Morgan, & Milazzo,
memory training was effective for a group et al., 1985; Sohlberg & Mateer, 1987;
1992). Comparison of outcome data for a
of 20 mildly to moderately impaired TBI Sohlberg et al., 1988).
group of TBI patients/clients who were in-
individuals, but not for a severely im- A multiple-baseline design is particu-
volved in the early intervention program
paired group. At the very least, the cog- larly well suited for intervention research
with a second group who did not undergo
nitive rehabilitation programs for more because it can deal with one of the pri-
this treatment indicated that the early in-
severely involved patients/clients need to mary confounding variables in determin-
tervention group had significantly shorter
be structured differently-with perhaps ing the effects of cognitive rehabilitation:
rehabilitation stays. Further, the early in-
more intensity, a greater degree of cue- spontaneous recovery. Only by demon-
tervention group was discharged at higher
ing and reinforcement, and longer dura- strating greater improvement in a trained
levels of cognitive functioning and had a
tion. In addition, without awareness of skill area than in a nontrained skill area
significantly higher percentage of dis-
deficits and motivation, it is difficult to can intervention effects be inferred. The
charges to home versus extended care
engage an individual with TBI in sus- multiple-baseline-across-behaviors de-
facilities. These findings are consistent with
tained and effective treatment (Ben- sign allows for this sequential intervention
previous reports regarding the benefits of
Yishay & Diller, 1993; Haarbauer-Krupa, and evaluation (Franzen & Harris, 1993).
early intervention (Cope & Hall, 1982).
Szekeres, & Ylvisaker, 1985). Finally, in- Furthermore, the use of multiple-baseline
dividuals with TBI benefit from programs designs permits clinicians, in the context
of cognitive rehabilitation as long after Differentiating Treatment of a fee-for-service setting with high pro-
onset as 4 (Cicerone & Wood, 1987) to Effects and Spontaneous ductivity expectations, to assess the effi-
6 (Boring, as cited in Benedict, 1989) Recovery cacy of their treatment and appropriately
years. Therefore, time post-onset should modify their interventions, online, without
not preclude an individual's participation Given the heterogeneity of TBI, it is the need for additional clinical time or cost
in such a program. extremely difficult to use group designs (Sohlberg, Sprunk, & Metzelaar, 1988).

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S12 Journalof Speech and Hearing Research 39 S5-S17 October 1996

TABLE 4. Summary of a sampling of treatment efficacy studies for social skills deficits reulting from TBI.

Study N Treatment focus Improvements/findings reported

Helffenstein & Wechsler 16 Role playing for interpersonal communica- Gains instaff ratings of everyday behavior
(1982) tion skills with videotape feedback and observer ratings of two interactions
Brotherton, Thomas, 4 Individual therapy with role-playing and 3 of 4 clients maintained improvement at
Wisotzek, & Milan (1988) videotape feedback for posture, speech 1-year follow-up; most stable gains were in
dysfluencies, self-manipulative behaviors, nonverbal skills; verbal social skills were not
and low frequency responding maintained at follow-up
Gajar, Schloss, Schloss, & 2 Group discussions and role-played Appropriate conversational responses
Thompson (1984) conversations using feedback and self- increased to normal range, but dropped
monitoring training when training was discontinued
Schloss, Thompson, Gajar, & 2 Heterosexual conversational interactions, to Compliments and questioning increased,
Schloss (1985) increase giving compliments, asking but self-disclosures did not decrease
questions, and to decrease inappropriate
self-disclosures using self-monitoring
training
Giles, Fussey, & Burgess 1 Conversational skills training to decrease Improvements in conversational skills
(1988) inappropriate behavior and tangentiality
using positive and negative reinforcement
Zencius, Wesolowski, & 1 Visual and verbal feedback to reduce Profanity decreased inthree settings
Burke (1990) profanity
Burke & Lewis (1986) 1 Behavior point system to decrease verbal Verbal outbursts and interruptions were
outbursts, interruptions, and nonsensical more responsive to treatment than
talk nonsensical talk

Lewis, Nelson, Nelson, & 1 Various types of feedback (attention, Client responded best to verbal corrections
Reusink (1988) (anoxic) ignoring, verbal correction) to decrease
impulsive, disinhibited, and inappropriate
social behaviors
Ehrlich & Sipes (1985) 6 Pragmatic skills: nonverbal communication, Greater improvements noted for linguistic
conversation, repairing communication skills than nonlinguistic
failures, and narrative cohesion using role-
playing and videotape feedback
Braunling-McMorrow, Lloyd, 3 Situational social skills: compliments, social Improvements noted inappropriateness of
& Fralish (1986) interaction politeness, criticism, confronta- mealtime social interactions, but no
tion, and questions and answers using generalization to other everyday social
hypothetical situations and gameboard behaviors

Summary of Program ceived speech-language pathology treat- Institute of Chicago-Functional Assess-


Evaluation Data ment in communication and cognition ment Scales (RIC-FAS, Heinemann,
and were discharged during a 12-month 1993). The two consistent elements in
An intrinsic limitation of all data man- period. A variety of commercially avail- all outcome measurement systems were
agement systems currently available to able and customized functional status that each used a 7-point rating scale and
speech-language pathologists is that, at measures were used to determine out- that data were obtained on patients/cli-
present, they are not sophisticated or comes by the five reporting facilities. ents at both admission and discharge.
sensitive enough to measure small in- These included the Functional Assess- Three of the facilities analyzed outcome
crements of functional change. It is with ment Measure (FAM, Santa Clara Valley data by the amount of improvement as
this knowledge that retrospective out- Medical Center, 1993), the Functional In- determined by the average percentage
come data were obtained from five well- dependence Measure (FIM, State Uni- of gain in functional score. The remain-
established, fully accredited inpatient versity of New York at Buffalo, 1990), the ing two sites analyzed outcome data by
rehabilitation programs throughout the Patient Evaluation and Conference Sys- the average percentage of patients/cli-
United States to determine whether any tem (PECS, Harvey &Jellinek, 1979), the ents who demonstrated functional im-
trends in outcomes could be identified. Rancho Rehabilitation Outcome Evalu- provement. The data provided by the fa-
Each facility provided data for all of ation (RROE, Rancho Los Amigos Medi- cilities were collected during calendar
their patients/clients with TBI who re- cal Center, 1993), and the Rehabilitation year 1992 or fiscal year 1992-1993 and

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Coelho et al.: Treatment Efficacy inCognitive-Communicative Disorders S13

included a total of 444 patients/clients. TABLE 5. Summary of program evaluation data for TBI patients receiving speech-lan-
Not all sites provided information on all guage pathology services from five inpatient rehabilitation facilities.
outcome measures. The data reported
indicate trends and reflect a weighted
average that is based on the total num- Treatment area Amount improvement Number patients improved
ber of patients/clients for whom data Average (%) Range (0%) Average (%) Range (%)
were available in each area.
All facilities reported length of stay Receptive language 16.4 8.3-22.9 69.4 67-82.5
(LOS) information. The overall average Expressive language 17.8 8.6-24.3 72.7 71-73
LOS, based on all 444 patients/clients, Speech production 9.7 7.7-12.6 71
Reading 10.3 7.3-14.9 88
was 46.3 days, with a range from 32.5 to Writing 11.3 6.9-18 77
58.4 days across facilities. Variability in Cognition 26.1 75
LOS is most often associated with fac-
tors that include patient/client acuity and Note. Data on functional outcomes inthe areas of receptive and expressive language represent
407 patients: 212 were analyzed by amount of improvement and 195 by percentage of func-
cognitive status upon admission, num- tional improvement. The speech production data represent 377 patients. Inthe areas of reading
ber of co-morbidities, severity of physi- and writing, data represent 160 patients: for cognition, the data represent 217 patients.
cal involvement, medical complications,
age, and length of time from onset to re-
habilitation admission. These factors also language, an average gain infunctional bilitation contribute to variations in the
may affect the severity of the cognitive- score of nearly 18% was reported, and trends reported. It is important to note that
communication disorder. It is important an average of approximately 73% of the these findings have been limited to inpa-
to note that the LOS data do not neces- patients/clients demonstrated improve- tient rehabilitation. Cognitive-communica-
sarily reflect the actual need for or length ment. Regardless of measure, the great- tive intervention should be provided as
of speech-language treatment program est functional improvement was seen in necessary along the continuum of care.
because clinicians traditionally have little the area of expressive language across Data related to the treatment benefits in
influence over LOS within the inpatient all facilities. both the pre- and postrehabilitation set-
rehabilitation setting. Four facilities reported speech pro- tings are needed.
Only four facilities reported data re- duction data from a total of 377 patients/ With the continued advancement in
lated to the discharge placements of their clients. The average gain in functional data management systems, the outcome
patients/clients. Of the 345 reported dis- score was approximately 10%. An aver- measurement tools used will become
charges, 83.5% (Range: 73.3%/96.2%) age of 71% of the patients/clients dem- increasingly refined and sensitive in the
were discharged home with or without onstrated improvement. monitoring of functional change. These
assistance; 10.7% (Range: 0%-20.0%) In the areas of reading and writing, systems will allow examination of follow-
were discharged to long-term care facili- three facilities reported data from 160 up as well as cost/benefit data and their
ties; and 5.8% (Range: 3.8%-9.0%) were patients/clients. For reading, average relationship to outcomes and will allow
discharged to other facilities (e.g., acute gain in functional score of over 10% was further examination of the long-term ef-
care settings) because of medical insta- noted, and an average of 88% of the fects of speech-language pathology ser-
bility and did not return to the compre- patients/clients exhibited improvement. vices in the rehabilitation process for
hensive rehabilitation program. The high For writing, an average gain of approxi- patients/clients with TBI.
percentage of patients/clients receiving mately 11% in functional score was re-
speech-language pathology services ported, and 77% of patients/clients dem-
who returned to the community is con- onstrated improvement. Summary
sistent with overall rehabilitation indus- Finally, in the area of cognition, only Several treatment efficacy studies of
try discharge placement data. two facilities reported data, which repre- cognitive rehabilitation were reviewed.
Functional outcome data were avail- sented 217 patients/clients. An average Results of these studies indicate that
able for 407 patients/clients in the ar- gain in functional score of 26% was there are a number of treatment tech-
eas of receptive and expressive lan- noted, and 75% of the patients/clients niques that have been successfully ap-
guage (see Table 5). The amount of demonstrated cognitive improvement. plied to deficits of attention, memory,
improvement, as determined by the av- These trends inthe functional improve- and executive functions in various TBI
erage percentage of gain in functional ment of cognitive-communicative abilities patients/clients. The heterogeneity of
score, involved a sample of 212 pa- (amount of functional improvement, num- TBI patients/clients prevents the appli-
tients/clients. The data from the remain- ber of patients/clients who improved, and cation of a generic treatment approach
ing sample of 195 patients/clients were the high percentage of patients/clients dis- for this population. For those patients/
analyzed by the average percentage of charged home) support the notion that a clients with more severe cognitive-com-
functional improvement. With regard to period of intensive inpatient rehabilitation municative deficits, treatment may be
receptive language, an average gain of is beneficial for cognitive-communicative more effectively directed toward the
over 16% in functional score was noted, deficits secondary to TBI. All such factors development of compensatory strate-
and an average of approximately 69% as the amount and rate of recovery, gies such as use of memory aids (e.g.,
of the patients/clients demonstrated premorbid abilities and status, and cogni- appointment book, alarm watch, or a
functional improvement. For expressive tive level at the time of admission to reha- detailed daily schedule). In those indi-

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S 14 Journalof Speech and HearingResearch 39 S5-S17 October 1996

viduals with profound deficits, treatment less severely injured group who had not following closed head injury. InJ. S.Kreutzer
may best be focused on environmental received treatment. Furthermore, when & P. H.Wehman (Eds.), Cognitive rehabilita-
tion forpersons with traumatic brain injury (pp.
modifications or the arrangement of per- patients/clients with similar severity of 75-86). Baltimore: Paul H.Brookes Pub.
manent support systems (e.g., training disabilities were compared, those who Adamovich, B. L. B., Henderson, J. A., &
family members/significant others to had received rehabilitation had better Auerbach, S. (1985). Cognitive rehabilitation
prompt patient/client during activities of average cost outcomes than those not of closed head injured patients. San Diego:
daily living) (Depompei & Williams, receiving rehabilitation services. College Hill Press.
1994; Story, 1991). Single-subject mul- Finally, future research regarding the Alexander, M.P., Benson, D.F., &Stuss, D.
tiple baseline designs are well suited for treatment efficacy of cognitive-commu- T.(1989). Frontal lobes and language. Brain
nicative disorders resulting from TBI and Language, 37, 656-691.
studying the efficacy of these ap-
proaches to cognitive rehabilitation. should address the following issues: (a) American Congress of Rehabilitation Medi-
cine. (1993). Definition of mild traumatic brain
Interventions directed at specific cog- representativeness of the TBI subjects injury. Journal of Head Trauma Rehabilitation,
nitive deficits are important; neverthe- (i.e., most of the studies completed to 8,86-87.
less, clinicians must address broader is- date have excluded very severely im- American Speech-Language-Hearing As-
sues of social skills retraining, timing of paired individuals or those with marked sociation. (1987). The role of speech-lan-
treatment during recovery, treatment lo- behavioral problems), (b)identification of guage pathologists in the habilitation of
cation and its effectiveness (e.g., hospi- subgroups of TBI patients with very spe- cognitively impaired individuals: Areport of the
subcommittee on language and cognition.
tal, home, school, work). The benefits of cific rehabilitation needs, and (c) broad- Asha, 29, 53-55.
early intervention were also stressed. ened criteria for a successful outcome American Speech-Language-Hearing Asso-
The treatment efficacy findings for TBI from cognitive rehabiliation to include ciation. (1990). Guidelines for speech-language
patients/clients were also supported by quality-of-life indices such as family re- pathologists serving persons with language,
data from five rehabilitation facilities that lationships and leisure activities. socio-communicative, and/or cog- nitive-com-
municative impairments. Asha, 32,85-92.
used various program evaluation sys-
tems. Although none of these data man- Acknowledgments Aronow, H.V.(1987). Rehabilitation effective-
ness with severe brain injury: Translating re-
agement systems are particularly sensi- The authors wish to thank those individu- search into policy. Journal of Head Trauma
tive to small incremental changes, the als who provided feedback on the initial draft Rehabilitation, 2, 24-36.
data revealed that functional gains were of this article: Brenda L.B.Adamovich, Roberta Benedict, R.H. B.(1989). The effectiveness
realized in receptive and expressive lan- DePompei, Danese Malkmus, McKay Moore of cognitive remediation strategies for victims
Sohlberg, and (inparticular) Mark Ylvisaker for of traumatic brain injury: A review of the litera-
guage, speech production, reading, writ- his extensive comments. Cynthia Thompson
ing, and cognition for TBI patients receiv- ture. Clinical Psychology Review, 9,605-626.
and two anonymous reviewers provided sev-
ing speech-language treatment. eral excellent suggestions for revising an ear- Ben-Yishay, Y., & Diller, L.(1993). Cognitive
lier version of this article. remediation in traumatic brain injury: Update
The cost/benefit of cognitive rehabili- and issues. Archives of Physical Medicine and
tation is supported by the findings of Rehabilitation, 74, 204-213.
Aronow (1987), who noted that inpatients References Ben-Yishay, Y., Piasetsky, E.B., & Rattock,
receiving rehabilitation services returned Adamovich, B.L.B. (1991). Cognition, lan- J. (1987). A systematic method for ameliorat-
to productive living at the same rate as a guage, attention, and information processing ing disorders inbasic attention. InJ.M.Meier,

Background performance evaluation tool, identification of problem areas


and possible solutions, development of a design strategy,
Milton (1988) described a 35-year-old man, a bank vice intensive practice, and refinement. Responsibility for
president, who was involved in a motorcycle accident that applying strategies and results was gradually shifted from the
resulted in a severe TBI. He was comatose for 5 weeks. After clinician to the patient/client.
4 months of comprehensive inpatient rehabilitation he had no
physical impairments but was left with subtle cognitive-
communicative deficits. Outcome
The patient/client returned to full-time employment at 9
Treatment months post-onset after 5 months of specialized assistance.
This individual then was enrolled in a rehabilitation
program designed to return him to work. Treatment sessions
were conducted by a speech-language pathologist at home
and at work; his wife, work supervisor, and secretary
assisted in the treatment sessions. The process involved
observation of the patient/client at work, development of a

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Coelho et al.: Treatment Efficacy in Cognitive-Communicative Disorders S15

A. L. Benton, & L. Diller (Eds.), Neuro- Crovitz, H. F. (1979). Memory retraining in Gianutsos, R., & Gianutsos, J. (1979). Re-
psychological rehabilitation (pp. 165-181). brain damage patients: The airplane list. Cor- habilitating the verbal recall of brain-injured
New York: Guilford Press. tex, 15, 131-134. patients by mnemonic training: An experimen-
Blosser, J. L., & DePompei, R. (1989). The Crovitz, H. F., Harvey, M.T., & Horn, R. W. tal demonstration using single-case method-
head injured student returns to school: Rec- (1979). Problems in the acquisition of imag- ology. Journal of Clinical Neuropsychology, 2,
ognizing and treating deficits. Topics in Lan- ery mnemonics: Three brain damaged cases. 117-135.
guage Disorders, 9, 19-32. Cortex, 15, 225-234. Gianutsos, R., & Gianutsos, J. (1987).
Braunling-McMorrow, D., Lloyd, K., & Davis, A. (1983). A survey of adult aphasia. Single-case experimental approaches to the
Fralish, K. (1986). Teaching social skills to Englewood Cliffs, NJ: Prentice Hall, Inc. assessment of interventions in rehabilitation.
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I. E., & Milan, M. A. (1988). Social skills train- ing with families after TBI: A family-centered ological considerations relevant to the compari-
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Background Treatment
Kreutzer, Wehman, Conder, and Morrison (1989) reported The clinician established a plan to improve the timeliness of
success with TBI patients/clients. One individual, a man in his work by using a log that listed each job, the expected
his thirties, sustained a moderate head injury in a motorcycle duration of the job, and projected completion date. In addition,
accident. Within one month post-injury he had recovered new jobs were accepted and scheduled on a tentative basis
physically but continued to demonstrate significant problems and only finalized after consulting with his wife, estimating
with memory, attention, reasoning, and organization, as well completion times liberally, and working on one job at a time.
as difficulty controlling his temper. He subsequently had to
give up his free-lance photography and college teaching;
instead he turned to painting and home renovation. A major Outcome
problem for this individual was organizing his work schedule. This process relieved a great deal of the man's stress.
He often took more jobs than he could handle and received Eventually he completed his master's degree, and although he
many complaints from customers about delays in job continued to work part-time as a contractor he resumed free-
completion. lance photography and began looking for part-time teaching
positions. He and his clinician were also working on organiza-
tional strategies intended to improve his teaching skills.

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S16 Journalof Speech and HearingResearch 39 S5-S17 OctobeT 1996

Heinemann, A. (1993). Rehabilitation Insti- lobes in traumatic brain injury. Journal of egies to brain-injured clients. Seminars in
tute of Chicago FunctionalAssessment Scales Neuropsychiatry, 6, 443-454. Speech and Language, 14, 1-16.
(RIC-FAS). Chicago, IL: Rehabilitation Insti- Lewis, F. D., Nelson, J., Nelson, C., & Prigatano, G. P., Fordyce, C. J., Zeiner, H.
tute of Chicago. Reusink, P.(1988). Effects of three feedback K., Roueche, J. R., Pepping, M., & Wood,
Helffenstein, D., &Wechsler, R.(1982). The contingencies on the socially inappropriate talk M. C. (1984). Neuropsychological rehabilita-
use of interpersonal process recall (IPR) in of a brain-injured adult. Behavior Therapy, 19, tion after closed head injury in young adults.
the remediation of interpersonal and commu- 203-211. Journal of Neurology, Neurosurgery and Psy-
nication skill deficits in the newly brain injured. Lezak, M. D. (1982). The problem of assess- chiatry, 47, 505-513.
Clinical Neuropsychology, 4, 139-143. ing executive functions. International Journal Rancho Los Amigos Medical Center.
Huber, L., & Edelberg, B. (1993). A com- of Psychology, 17, 281-297. (1993). Rancho Rehabilitation Outcome
munity integration model of head injury re- MacKay, L. E., Bernstein, B.A., Chapman, Evaluation (RROE). Downey, CA: Author.
habilitation. Journal of Cognitive Rehabilita- P. E., Morgan, A. S., & Milazzo, L. S. (1992). Richardson, J. T. E. (1984). The effects of
tion, 11, 22-26. Early intervention in severe head injury: Long- closed head injury upon intrusions and con-
Jacobs, H.E. (1988). The Los Angeles head term benefits of a formalized program. Ar- fusions in free recall. Cortex, 20, 413-420.
injury survey: Procedures and initial findings. chives of Physical Medicine and Rehabilita-
tion, 73, 635-641. Ruff, R. M., Baser, C. A., Johnson, J. W., &
Archives of Physical Medicine and Rehabili- Marshall, L. F. (1989). Neuropsychological
tation, 69, 425-431. Malec, J. (1984). Training the brain-injured rehabilitation: An experimental study with
Jennett, B., Snoek, J., Bond, M., & Brooks, client inbehavioral self-management skills. In head-injured patients. Journal of Head
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