Brain Injury Professional Volume 7 Issue 2

B R A IN INJURY professional vol. 7 issue 2

The official publication of the North American Brain Injury Society

Educating Children and Adults after Brain Injury Effective Inst r u c t i o n : Optimizing Ou t c o m e s F o l l o w i n g A B I Post-Acute Adu l t C o n t i n u i n g Education afte r T B I

C o a s t l i n e C o m m u n i t y C o l l ege P e n n s y l v a n i a ’ s B r a i n S T E PS: C h i l d & A d o l e s c e n t B r a i n Injury School Re-Entry Program

The Pediatric A c q u i r e d B r a i n Injury Plan

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contents

BRAIN INJURY professional vol. 7 issue 2

The official publication of the North American Brain Injury Society

north american brain injury society

departments 4 Editor in Chief’s Message 6 Guest Editor’s Message

chairman Ronald C. Savage, EdD Immediate Past Chair Robert D. Voogt, PhD treasurer Bruce H. Stern, Esq. family Liaison Skye MacQueen executive director/administration Margaret J. Roberts executive director/operations J. Charles Haynes, JD marketing manager Megan Bell graphic designer Nikolai Alexeev administrative assistant Benjamin Morgan administrative assistant Bonnie Haynes

26 bip Expert Interview brain injury professional

publisher J. Charles Haynes, JD Editor in Chief Ronald C. Savage, EdD Editor, Legislative Issues Susan L. Vaughn founding editor Donald G. Stein, PhD design and layout Nikolai Alexeev advertising sales Megan Bell

28 Non-profit News 29 Book Reviews 30 Legislative Round-up

EDITORIAL ADVISORY BOARD BRAIN INJURY professional vol. 7 issue 2

The official publication of the North American Brain Injury Society

Educating Students with Brain Injury Effective Instruction: Optimizing Outcomes Following ABI Post-Acute Adult Continuing Education after TBI

Coastline Community College Pennsylvania’s BrainSTEPS: Child & Adolescent Brain Injury School Re-Entry Program

The Pediatric Acquired Brain Injury Plan

Michael Collins, PhD Walter Harrell, PhD Chas Haynes, JD Cindy Ivanhoe, MD Ronald Savage, EdD Elisabeth Sherwin, PhD Donald Stein, PhD Sherrod Taylor, Esq. Tina Trudel, PhD Robert Voogt, PhD Mariusz Ziejewski, PhD

editorial inquiries BRAIN INJURY PROFESSIONAL

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features 8 Effective Instruction: Optimizing Outcomes Following ABI

by Laurie Ehlhardt, PhD; Patricia Sublette, PhD; Ann Glang, PhD 14 Post-Acute Adult Continuing Education after TBI

By Stacy Levesque, MA CCC-SLP, CBIS, Justin Moses, CBIS, Hector Gutierrez, CBIST, Christin Moses 20 The Pediatric Acquired Brain Injury Plan

by Roberta DePompei, PhD 22 Coastline Community College

by Celeste Ryan, ms, Michelle Ranae Wild, ma, Sandra P. Klein, phd 24 Pennsylvania’s BrainSTEPS:

Child & Adolescent Brain Injury School Re-Entry Program

by Brenda Eagan Brown, MSEd, CBIS

Managing Editor Brain Injury Professional PO Box 131401 Houston, TX 77219-1401 Tel 713.526.6900 Fax 713.526.7787 Website: www.nabis.org Email: contact@nabis.org

advertising inquiries Megan Bell Brain Injury Professional HDI Publishers PO Box 131401 Houston, TX 77219-1401 Tel 713.526.6900 Fax 713.526.7787

national office

North American Brain Injury Society PO Box 1804 Alexandria, VA 22313 Tel 703.960.6500 Fax 703.960.6603 Website: www.nabis.org Brain Injury Professional is a quarterly publication published jointly by the North American Brain Injury Society and HDI Publishers. © 2010 NABIS/HDI Publishers. All rights reserved. No part of this publication may be reproduced in whole or in part in any way without the written permission from the publisher. For reprint requests, please contact, Managing Editor, Brain Injury Professional, PO Box 131401, Houston, TX 77219-1400, Tel 713.526.6900, Fax 713.526.7787, e-mail mail@hdipub.com

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editor in chief’s message

Ronald Savage, EdD

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This issue of BIP focuses upon the continuing education of individuals who have sustained brain injuries. Not just for school-age children, but for adults as well. As we all know, education remains a cornerstone in the advancement of all of us, and for individuals with brain injuries continuing education needs be an integral part of our treatment milieu. Learning in isolation does not work. Learning in context, especially when that context is important to the person, is fundamental. It is fundamental to our sense of self, our confidence, and our feelings of self worth.

For children and adolescents, their education continues and their special education needs are protected by the Individuals with Disabilities Education Act (IDEA). The issue for school-age children is more about what types of instructional methods will work best for them. What do their teachers and special education teams need to know? What kinds of evidenced-based practices for students with brain injuries get the best outcomes? Yet, for adults, it is a different world. Sometimes ongoing education of adults after brain injuries just stops, even for our young college-age adults. While certain clinical therapies and services may continue for individuals, their opportunities for continuing education falls by the wayside.

As professionals, we know that we are

constantly trying to keep up with local, national and world events through the news. We are continually trying to keep ourselves educated about our professions through conferences, CEU courses, seminars and the like. We have technology that allows us to “continue our education” right in the comforts of our own homes. Webinars, YouTube, IPads, Twitter, TED, the world is full of continuing education for us.

Dr. Janet Tyler tackles this complex issue for us. How can we effectively continue the education of children, adolescents, young adults and adults with brain injuries? How can use existing and new methodologies to better educate individuals in school, in post-secondary options, in post-acute BI programs? How do we incorporate continuing education into the clinical treatment of the individuals we serve? Dr. Tyler’s authors address these challenges and provide practical recommendations. In addition, a stellar interview with Marilyn Lash provides us with a guide to parents’ needs and wants for their school-age children.

NABIS thanks Dr. Tyler and her colleagues for a unique look at the continuing education of individuals with brain injuries. The articles are engaging and full of useful ideas and models we can replicate.

Ronald Savage, EdD

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guest editor’s message

Janet Siantz Tyler, PhD An infant is abused by a caregiver, a ten year old falls out of a tree, a teenager is involved in a motor vehicle crash, a young adult suffers a gunshot wound to the head – all sustain brain injuries that leave them with challenges which will impact their lifelong learning. In this issue of Brain Injury Professional we focus on the education of individuals with brain injury, from the school years through postsecondary education and beyond, by providing information on best instructional practices and highlighting unique programs designed to address specialized learning needs.

For over two decades I have been engaged in developing and delivering inservice and preservice training to educational professionals to help them understand and meet the learning needs of students with brain injury. I believe that I, along with my colleagues throughout the country who have undertaken this task, have indeed made significant progress in increasing the knowledge of numerous educators in the area of TBI. However, we realize the need for the ongoing nature of such efforts and understand there is still much work to be done in this area. While there are many excellent educators in our school and community systems that truly strive to provide the best for all learners, many still lack the training and experience to effectively address the distinct learning needs of individuals with brain injury.

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Only through continued awareness of the need for specialized knowledge and preparation for educators, ongoing training efforts, and programs specifically designed to address unique learning needs, will individuals with brain injury be afforded appropriate educational opportunities.

Thus, I am honored to serve as guest editor for Brain Injury Professional as this issue provides yet another opportunity to increase the awareness and knowledge of those that provide educational services to individuals with brain injury.

The lead article, Effective Instruction: Optimizing Outcomes Following ABI, by Drs. Laurie Ehlhardt, Patricia Sublette, and Ann Glang sets the stage for this edition by pointing out that the learning difficulties individuals with brain injury experience are often due in part to a lack of systematic instruction designed to address their individual learning needs. Dr. Ehlhardt and her colleagues provide us with an overview of evidence-based instructional principals and offer practical examples of the use of these principals to instructional targets common to schoolaged students and adult learners with cognitive impairments due to brain injury.

Two promising programs that systematically address the learning needs of children and youths with brain injury are described in this issue. Dr. Roberta DePompei’s article provides us with an overview of the national Pediatric Acquired Brain Injury Plan (PABI), a comprehensive national plan of care, agreed upon by key researchers and clinicians, representing best practices for children, adolescents, and young adults with brain injuries. Brenda Eagan Brown, in her article Pennsylvania’s BrainSTEPS: Child & Adolescent Brain Injury School Re-Entry Program, presents an example of a statewide program that provides for the training of educational teams to provide consultation to schools to ensure educators are knowledgeable about brain injury and prepared to provide the interventions and supports necessary to ensure educational success for school-aged students with brain injury.

In our Expert Interview section, Marilyn Lash, with her long history of experience and considerable expertise work-

ing with families of children and youths with brain injury, provides the answers to several of the most commonly asked questions she receives from parents about school issues following their child’s brain injury.

Of course, for the majority of individuals, the need and desire for learning doesn’t cease upon graduation from high school. Because learning continues throughout one’s lifetime, it’s important that adults with brain injuries have available to them programs that address their ongoing learning needs. Two such programs are highlighted in this edition. In their article, Post-Acute Continuing Education, Stacy Levesque, Justin Moses, and Hector Gutierrez describe an innovative inter-disciplinary approach to improving independent living, new learning, and cognitive-linguistic skills for adults with brain injury. This unique post acute adult continuing education program uses a format of a “university type” curriculum distinctively crafted to fit the needs of individuals with brain injuries.

An example of a post-secondary education program for individuals with brain injuries is provided by Celeste Ryan, Michelle Ranae Wild and Dr. Sandra P. Klein. The authors describe Coastline Community College’s long-standing Acquired Brain Injury Program designed to provide cognitive and psychosocial retraining for adults who have sustained brain injuries. The program, with its proven outcomes, offers a fine example of a high quality structured educational program that serves as the model for postsecondary education of adults with brain injury.

I would like to thank each of the authors, not only for their valuable contributions to this issue, but also for the very work they do to ensure that individuals with brain injury are afforded appropriate educational opportunities designed to meet their ongoing learning needs. Additionally I would like to express my gratitude to Dr. Ron Savage and Chas Haynes for their support and assistance with this issue.

Janet Siantz Tyler, PhD

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Effective Instruction: Optimizing Outcomes Following ABI

by Laurie Ehlhardt, PhD; Patricia Sublette, PhD; Ann Glang, PhD Overview of Instruction for ABI

An educator, school psychologist, occupational therapist, and speech-language pathologist working with the following individuals with acquired brain injury (ABI) discover that:  Ben, 10 years old—struggles with reading comprehension; he’s failing language arts.  Elena, 28 years old—fails to complete all of her clerical tasks at work and is at risk for losing her job.

These two learners have one thing in common: they have not had systematic instruction to help them learn, generalize, and retain the information, skills and strategies they need to be successful in their daily activities. Instruction is one of the most important yet often over-looked aspects of working with children and adults with cognitive impairments due to ABI. Providing learners with clear instruction can help them learn skills and strategies that will help them be more successful at school, home, work, and in the community. In this issue of the Brain Injury Professional, we provide an overview of evidence-based instructional principles, and then apply these principles to instructional targets common to students and adults with cognitive impairments due to ABI. Review of the Evidence

The field of neuropsychological rehabilitation has witnessed a rapid expansion of research dedicated to the topic of instruction over the past several years. Researchers have evaluated several instructional techniques and practices, including (a) errorless learning—minimizing or eliminating errors during the acquisition phase of learning (e.g., Baddeley & Wilson, 1994); (b) spaced retrieval—a form of distributed practice in which the learner is provided opportunities to successfully recall information over expanded time intervals (e.g., Melton & Bourgeois, 2005); and (c) systematic support—instructors grade the level of support they 8

BRAIN INJURY PROFESSIONAL

provide according to the severity of learner’s cognitive impairments and the stage of learning (e.g., Riley & Heaton, 2000).

Various terms used to describe such support include “prompts,” “cues,” and “scaffolding” (e.g., Sohlberg & Turkstra in press; Ylvisaker et al., 2000). In a recent review of the literature on effective instruction for individuals with acquired memory impairments Ehlhardt et al., (2008) identified key instructional practices for use with this population.  Clearly define the instructional target(s) (e.g., information, multi-step skills, cognitive strategies).  Insure the target is relevant and personally meaningful to the client.  Minimize errors during the acquisition phrase (i.e., errorless learning), particularly for those with more severe impairments.  Provide high rates of correct practice.  Provide opportunities to practice over increasingly longer periods of time (i.e., spaced retrieval).  Use multiple training examples.

These techniques must be flexible and individualized, taking into account the learner’s abilities, motivation, and task characteristics (Clare & Jones, 2008; Ehlhardt et al., 2008; Fillingham, Sage, & Lambon Ralph, 2006; Riley & Heaton, 2000; Sohlberg & Turkstra, in press). Although there is no single way to instruct someone with acquired cognitive impairments, research clearly shows that instruction must be carefully planned to include the specific features listed above. Over 40 years of research in special education validates these same instructional techniques with both children and adults with learning challenges (Stein, Carnine, & Dixon, 1998; Swanson, 1999, 2001). This body of work, examining the most effective way to teach learners with different disability labels but similar functional challenges, is relevant to designing effective approaches for teaching individuals

with ABI (Ylvisaker et al., 2005).

Central to effective instruction is the assessment-instructional cycle. This framework is comprised of four steps—assessment, instructional design, instructional delivery, and on-going assessment (see Figure 1 below) (Madigan, Hall, & Glang, 1997).

Figure 1

Steps 1-4. (Modified from Glang, Todis & Singer, 1997)

Step 1: Assessment 1. Conduct comprehensive background assessment 2. Identify instructional goals

Step 4. On-going Assessment 1. Collect data 2. Reflect on/analyze patterns

Step 2: Instructional Design 1. Identify instructional targets 2. Assess stage of learning 3. Identify places where teaching will occur 4. Identify people to include in the teaching process 5. Design instructional materials 6. Select teaching examples 7. Identify clear instructional wording

Step 3. Instructional Delivery Include the following: 1. Modeling and systematic support 2. High amounts of practice–review 3. Appropriate pacing 4. Corrective and positive feedback 5. Teaching to mastery

Effective Assessment-Instruction Cycle Step 1. Assessment: Assessment is an essential first step in the instructional process.

Ask: What does the learner know and what are his/her current abilities?

1. Conduct comprehensive background assessment: Assess the learner’s abilities and needs across multiple domains (e.g., cognitive-communicative, academic, social; vision, hearing, motor, etc.), using a variety of sources (i.e., standardized and informal assessment tools, observations across settings) 2. Identify instructional goals: Determine the learner’s goals through interviewing the learner and relevant others (e.g., teachers, parents, spouses, co-workers)

Step 2. Instruction Design: Instructional design is an extension of the assessment process and should take place before instruction occurs.

Ask: What additional information/skills/strategies does the learner need to know?

1. Identify instructional target(s): Determine what the learner needs to know or be able to do in order to achieve his or her goal. Determine the type of instructional target from one of three broad categories: a. Information-Concepts: Information—specific facts or important pieces of information such as name or phone number; Concepts—an object, event, action, or situation that is part of a class of information (e.g., spelling regular vs. irregular words; sorting colored vs. white clothing). b. Multi-step skills/procedures: Multi-step tasks for specific activities such as making a sandwich, checking an appointment on a calendar, or turning in homework are broken down into small steps (i.e., task analysis). c. Rules-Cognitive Strategies: Rules—specific “if-then” connections between facts or concepts (e.g., If you see water on the floor, then mop it up.); Strategies—used to selfregulate behavior or thinking for either: (a) specific tasks such as PQRST (Preview, Question, Review, State, Test)

for reading comprehension; or (b) a range of tasks such as Goal-Plan-Do-Review to facilitate goal planning and follow through.

2. Assess stage of learning: Once the instructional target has been determined, assess (i.e., take baseline data) to determine current level of performance on specific instructional target: Stage 1: Acquisition—the beginning stage; the learner has minimal or no knowledge of the instructional target; Stage 2: Generalization—acquisition achieved but the learner has yet to generalize to other contexts; Stage 3: Maintenance—the learner maintains generalized information, skills, and/or strategies over time.

Ask: What is the instructional environment(s)?

In order to facilitate generalization of learning across settings and people, it is important to include, early on in the instructional process, teaching in a variety of settings with different people.

1. Identify places where teaching will occur: Determine where functional use of the target is expected to occur (e.g., classroom, office, reception desk, work site, grocery store, recreational events, etc).

2. Identify people to include in the teaching process: Determine the people with whom the learner will use the instructional target (s) (e.g., classmates, teacher, spouse, co-workers, supervisors, community members, etc).

Ask: What do I need to prepare ahead of time?

1. Design instructional lessons/materials/units: Organize and modify as needed the instructional materials (e.g., reading material, math problems, external aids). A key component of this step is breaking down complex skills into component parts (e.g., checking appointments using a PDA–step 1 turn on PDA; step 2 locate date; step 3 press the date...).

2. Select teaching examples: Select and sequence multiple acquisition and generalization teaching examples. It is critical to consider the range of examples needed to teach most efficiently (e.g., to teach simple cooking, it is important to work with a variety of recipes and ingredients).

3. Identify clear wording: Make sure directions/models are worded simply and clearly; develop an instructional script to keep wording consistent across examples.

Step 3. Instructional Delivery: Instructional delivery is what the instructor actually does during the class or therapy session.

Ask: What are the specific instructional delivery techniques that will be used?

1. Modeling: Demonstrate target (s) and provide systematic support tailored to the learner’s abilities and stage of learning (1-3 above).

2. Practice-Review: Provide learner with multiple practice opportunities distributed throughout each session (e.g., spaced retrieval) and provide review opportunities across sessions.

3. Pacing: Appropriately pace modeling and practice trials at a rate consistent with the learner’s processing speed.

4. Feedback: Provide immediate corrective feedback in response to errors; reinforce correct performance.

5. Mastery: Train instructional targets to mastery before introducing new material. (See Table 1 for instructional techBRAIN INJURY PROFESSIONAL

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niques linked to learner’s characteristics).

Step 4: On-going Assessment: Conduct on-going assessment to determine the effectiveness of instruction.

Ask: How will I know if the instruction is effective?

1. Collect data: Record the learner’s performance on instructional targets at the beginning of each training session.

2. Reflect on/analyze patterns: Use the data to determine level of mastery and the need for modifying the design and delivery of instruction. Assess the learner’s motivation and attitude to insure continued engagement in the instructional process.

Two hypothetical case examples are presented below to illustrate the assessment-instruction cycle. To better focus on the instructional component of each case, information on background assessment has been kept to a minimum. table 1

Research-based instructional strategies related to characteristics of individuals with ABI (modified from Ylvisaker et al., 2001).

TBI characteristics

Instructional strategy

Description

Fluctuating attention

Appropriate pacing

Delivering material in small increments and requiring response at a rate consistent with a learner’s processing speed increases acquisition of new material.

High rate of success

Acquisition and retention of new information tends to increase with high rates of success. This requires careful selection and sequencing of practice examples to ensure learner provides correct responses.

Decreased speed of processing

Memory impairment (associated with need for errorless learning) High rates of failure

Case Examples Student Case Example: Penny and Ben

Focus: Improving reading comprehension Overview: Ben is a ten year-old in Penny’s 5th grade class who sustained an ABI one year ago while riding his bike. Ben is having difficulty with reading comprehension. Penny needs to assess Ben’s reading comprehension and design and deliver instruction in a group setting to help him improve this core academic area.

Step 1. Assessment: Assessment is an essential first step in the instructional process.

Ask: What does the learner know now?

1. Background: The school psychologist’s assessment revealed moderate difficulty with new learning, but relatively spared attention and executive functions. Vision, hearing, and motor skills are within-normal limits. Results from a reading assessment suggest that Ben is able to read words and recall facts but has difficulty locating main ideas in a paragraph.

2. Goal: Ben will identify the main idea and supporting details in grade-level reading material with 90% accuracy.

Step 2. Instruction Design: Instructional design is an extension of the assessment process and should take place before instruction occurs.

Ask: What additional information/skills/strategies does the learner need to know?

1. Instructional target(s): Peggy determines that Ben does not understand the concept of main idea vs. supporting details, 2. Stage of learning: Ben is currently at the acquisition stage of learning for comprehending main vs. supporting ideas; he can state the main idea in three out of ten paragraphs during 10 BRAIN INJURY PROFESSIONAL

baseline testing with grade-level material. He is not ready for generalization or maintenance.

Ask: What is the instructional environment(s)?

1. Places: Penny will instruct Ben in a small group with five other students who are experiencing similar challenges. Once Ben achieves mastery in Penny’s classroom, she will work with Ben’s parents to practice this concept with him at home.

2. People: Ben will be able apply the target concept with a variety of people, including Penny, classroom aides, peers, and parents.

Ask: What do I need to prepare ahead of time?

1. Materials: Penny selects paragraph-length materials from published reading curricula.

2. Examples: Penny initially chooses familiar, paragraph-length examples slightly below Ben’s grade level. Paragraphs range in length from two to three sentences to ten sentences. For initial instruction, she uses multiple-choice examples/nonexamples of main ideas of each paragraph. As Ben masters the concept of main idea, Penny advances to more complex, grade-level material to facilitate generalization. Penny uses at least four to five different examples per lesson.

3. Wording: Penny uses an instructional script that comes with the published reading program to insure clear, concise delivery. Here is a sample script from one of their first lessons together.

Sample script: Teacher: The main idea of a paragraph tells what the whole paragraph is about.

Teacher: What does the main idea tell you?

Student: What the whole paragraph is about.

Teacher: Excellent. Ben please read the first paragraph.

Ben: Every day Sara got up early before school and took care of her dog, Fred. She took Fred for a walk then fed him before leaving for school. She took him for another walk after she finished her homework at night. Before going to bed, she combed his fur and gave him a doggy biscuit to clean his teeth.

Teacher: Nice job. Let’s figure out the main idea for this paragraph. Remember, the main idea tells what the whole paragraph is about. (Reads aloud the four choices on the board) Teacher: The main idea is #3: Sara takes care of her dog. It tells you what the whole paragraph is about. The other choices only tell about part of the paragraph.

Teacher: Let’s do another example. (After two more paragraphs with Penny modeling how to identify the main idea, she asks another student to read a fourth paragraph again with four multiple choice options) Teacher: Let’s review: What does the main idea tell you? (Calls on Ben.) Ben: The main idea tells you what the whole paragraph is about.

[Teacher and Students review all main idea options] Teacher: Is answer #2 the main idea for this paragraph? (Calls on another student.)

Student: No Teacher: Why? Student: Because it doesn’t tell about the whole paragraph.

Teacher: Ben: Teacher: Student:

Tell me, is #3 the main idea? Why or what not?

(Calls on Ben.) It’s not the main idea because it doesn’t tell about the whole paragraph.

How about #1? (Calls on another student.)

It is the main idea because tells about the whole paragraph.

Step 3. Instructional Delivery: Instructional delivery is what the instructor actually does during the class or therapy session.

Ask: What are the specific instructional delivery techniques that will be used?

1. Modeling: In the sample script above, Penny models how to identify the main idea across three paragraphs followed by guided practice with a fourth paragraph. [Note: It is through practice with multiple examples that Ben begins to generalize the concept; she moves from simple conceptual understanding to strategic application.]

2. Practice–Review: The students practice locating the main idea in simple paragraphs, selecting from multiple-choice options. Penny monitors and provides corrective feedback and praise.

3. Pacing: Penny determines the pace of instruction by observing how her students are doing and paces the lesson to the average learner in the group. If they are responding correctly and fairly quickly, she moves briskly through the lesson. If they have difficulty, she provides more models of how to use the strategy.

One cautionary note regarding instructional pacing— sometimes instructors make the mistake of slowing down instruction to match the response speed of students with articulation disorders or response latency. This is acceptable to a point, but extremely slow presentation can lead to distraction or confusion (e.g., the learner may have trouble tracking or remembering question).

4. Feedback: If she notices Ben or any other student giving incorrect responses, Penny immediately corrects by providing the correct answer, and then having students practice another example.

5. Mastery: Penny continues this exercise until all the students are able to identify the main idea in a multiple choice format with 90% accuracy without assistance. She then asks students to read simple paragraphs and state the main idea for each. If students do not correctly identify the main idea, she follows the correction procedure above. Once students can state the main idea with 90% accuracy, she moves to more complex paragraphs.

Step 4. On-going Assessment: Conduct on-going assessment to determine the effectiveness of instruction.

Ask: How will I know if the instruction is effective?

1. Data: At the beginning of each session, Penny takes data to determine how well the students can find the main idea on a novel passage. This helps guide what she needs to focus on during that day’s lesson. If they have trouble, she will provide more practice. If they are doing well, she will move to more difficult examples, or on to a new skill.

2. Reflection: After each session, Penny reflects on her teaching to determine what she might do differently in the next session. Following the above lesson for example, she determines that her pacing was a little slower than the group needed

which was likely why some students were not attentive. She also determined that she needed to give more practice opportunities to help students master the strategy. She felt good about her instructional wording and feedback.

Adult Case Example: Alan and Elena

Focus: Completing all job-related tasks.

Overview: Alan is a job coach in a vocational re-entry program for adults with acquired brain injury. In consultation with a speech-language pathologist (SLP), he is providing twice weekly support and training to Elena, a 28-year-old woman who sustained a traumatic brain injury in a car crash. Elena is working in a doctor’s office. Her duties include filing medical charts, organizing the mail, stuffing envelopes, and answering the phone.

After one month on the job her immediate supervisor reports that Elena is highly motivated, works well with other staff and patients, and is fielding phone calls very well. Her current challenges involve remembering to do her other clerical tasks; she gets distracted when she answers the phone or engages in conversation with patients and never completes her filing or mail work.

Alan, Elena, and the office staff agree that they need to figure out a system for helping her remember to accurately and efficiently complete her filing tasks.

Step 1. Assessment

Ask: What does the learner know now?

1. Background: Elena lives with her husband; they have no children. Neuropsychological testing revealed that Elena has significant difficulties with attention and working memory but has relatively spared new learning/memory and selected components of executive functions (e.g., initiation, planning). She has a mild tremor in both hands but it does not interfere with daily tasks. Vision and hearing are within normal limits. Initial vocational testing and further assessment by the SLP reveal that Elena might benefit from an external aid that would help cue her to complete all of her work tasks.

The SLP, Alan, and Elena decide that instructing her to respond to regular alarms in the “tasks” program on her cell phone would be the most appropriate instructional target, since she always has her cell phone with her and this same skill could transfer to other daily tasks. (Note: They decide to delay teaching her how to program these alarms until she has mastered responding to alarms programmed by someone else.)

2. Goal: Elena will complete all clerical work tasks 80% of the time, using her cell phone alarm to prompt task completion.

Step 2. Instruction Design

Ask: What additional information/skills/strategies does the learner need to know?

1. Instructional target(s): Alan and the speech-language pathologist working with Elena determine that responding to the cell phone alarms and completing the prompted task is a multi-step skill. The steps include the following: Step 1. Pick up the cell phone (when the alarm goes off ) Step 2. Read task (e.g., file charts, organize mail) Step 3. Press Snooze Step 4. Start task Step 5. Press OK once alarm goes off again (These steps insure she has actually started the task before the BRAIN INJURY PROFESSIONAL

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alarm is turned off.)

2. Stage of learning: After just a few sessions with the SLP working together at the vocational re-entry program office, Elena has mastered each of the above steps, consistently completing the steps during a role play (Stage 1–acquisition). The SLP taught Elena just 1-2 steps at a time until all 5 steps were mastered. Now Elena needs to generalize this 5-step skill to the work setting with Alan’s help and at home with her husband’s help. Once the skill is mastered, Alan will conduct maintenance checks.

2. Practice–Review: Elena practices the 5-step process at least six times per shift with Alan.

3. Pacing: Alan adjusts his instructional pacing to match Elena’s day-to-day fluctuation in attention, fatigue, etc.

4. Feedback: Alan provides immediate feedback concerning Elena’s recall of the 5-steps as well as her performance on the target task itself.

5. Mastery: Elena continues to work on the 5-step skill at work and at home until mastered.

Ask: What is the instructional environment(s)?

1. Places: Elena will receive instruction at home and at work.

2. People: While at work, Elena will incorporate the new skill into her work among office staff and patients. At home, she will use the skill to prompt completion of home-based activities (e.g., laundry, cleaning) she does on her own.

Ask: How will I know if instruction is effective?

1. Data: At the beginning of each session and throughout the course of her shift, Alan and Elena’s work supervisor take brief notes on how well she is completing her work tasks.

Alan also checks in with her husband to see how she is doing at home with cell phone alarms to prompt task completion.

2. Reflection: Before each work shift, Elena predicts how she will do with her 5-step skill. Then she and Alan reflect on her performance at the end of each shift, consulting with the work supervisor, as appropriate.

Ask: What do I need to prepare ahead of time?

1. Materials: Elena needs her cell phone and the materials needed to complete the targeted work and home tasks (e.g., files, envelopes, cleaning products).

2. Examples: Alan and Elena generate a list of all the work tasks she has to do besides answering the office phone (e.g., filing, organizing mail, stuffing envelopes) and with her supervisor, agrees on a schedule for programming her cell phone alarms to go off, insuring there are sufficient practice opportunities to help her with skill generalization (e.g., a minimum of 6 alarms per shift; 2 each across 3 different tasks). Alan programs these alarms before the shift begins. Similarly, Elena and her husband develop a list of home tasks that require prompting via cell phone alarms.

3. Wording: Alan uses an instructional script to insure clear, concise delivery. Here is a sample script: [first alarm goes off at 9:00 am] Alan: [Waits to see if Elena picks up the phone] Elena: [She picks up the phone.] (Step 1 above) Elena: It says ‘file charts’. (Step 2) Alan: Okay. [waits to see if she does anything. When she doesn’t, he asks] And then?

Elena: Oh, then I press ‘Snooze’ [presses “Snooze”] (Step 3) Alan: Great!

Elena: [initiates filing charts] (Step 4) [alarm goes off again] Alan: And now?

Elena: I press OK (Step 5) Alan: Good job!

Elena: [continues filing charts]

Step 4. On-going Assessment

SUMMMARY

This series of articles introduces effective instructional practices for training individuals with ABI on personally-relevant information, skills, and strategies. The overview of the 4-stage assessment-instruction process was illustrated with two case examples that represent the age range, diagnoses, and instructional targets professionals may encounter. The purpose of this approach is to illustrate that time spent prior to actually beginning training—on assessment and instructional design—followed by clear, targeted instruction, delivery, results in faster mastery of skills and strategies, improved generalization, and greater retention.

The readers are strongly encouraged to further explore evidencebased instruction through the resources listed below: Kennedy, M.R.T. & Coelho, C. (2005). Self-regulation after traumatic brain injury: A framework for intervention of memory and problem solving. Seminars in Speech and Language, 26, 242-255.

Sohlberg, M.M., Ehlhardt, L., & Kennedy, M. (2005). Instructional techniques in cognitive rehabilitation: A preliminary report. Seminars in Speech and Language, 26, 268-279.

Sohlberg, M.M., Kennedy, M.R.T., Avery, J., Coelho, C., Turkstra, L., Ylvisaker, M., & Yorkston, K. (2007). Evidencebased practice for the use of external aids as a memory rehabilitation technique. Journal of Medical Speech Pathology, 15(1), xv-li.

Sohlberg, M.M.& Turkstra, L. (in press). Cognitive Rehabilitation: Teaching New Skills, Strategies and Facts to People with Acquired Brain Injury. New York: Guilford Press.

Step 3. Instructional Delivery: Remember

Ask: What are the specific instructional delivery techniques that will be used?

1. Modeling: Given Elena’s relatively mild impairments and skill-comfort using the cell phone, Alan provides minimal direct support up front, offering indirect questioning cues instead (e.g., And then? And now?) Should she forget a step, he increases the specificity of his support (e.g., Read what it says. Do the task.)

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References 1.

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Baddeley A. Wilson B.A. When implicit learning fails: Amnesia and the problem of error elimination. Neuropsychologia. 32(1): 53–68, 1994.

Clare L. Jones RSP. Errorless Learning in the Rehabilitation of Memory Impairment: A Critical Review. Neuropsychology Review. 18(1): 1-23, 2008.

Ehlhardt L. Sohlberg MM. Kennedy MRT. Coelho C. Turkstra L. Ylvisaker M. Yorkston K. Evidence-based Practice Guidelines for Instructing Individuals with Acquired Memory Impairments: What Have We Learned in the Past 20 Years? Neuropsychological Rehabilitation. 18(3): 300-342, 2008.

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Fillingham JK. Sage K. Lambon Ralph MA. The treatment of anomia using errorless learning. Neuropsychological Rehabilitation. 16(2): 129-154, 2006.

Glang A. Singer GHS. Todis B (Eds.) Children with Acquired Brain Injury: The School’s Response. Baltimore: Paul H. Brookes, 1997.

Glang A. Ylvisaker M. Stein M. Ehlhardt L. Todis B. Tyler J. Validated instructional practices: Application to students with TBI. Journal of Head Trauma Rehabilitation. 23(4): 243251, 2008.

Kennedy MRT. Coelho C. Turkstra L. Ylvisaker M. Sohlberg MM. Yorkston K. Chiou HH. Kan PF. Intervention for executive functions after traumatic brain injury: A systematic review, meta-analysis and clinical recommendations. Neuropsychological Rehabilitation.

18(3): 257-299, 2008.

Riley G. Heaton S. Guidelines for the selection of a method of fading cues. Neuropsychological Rehabilitation. 10(2): 133–149, 2000.

Madigan KA. Hall TE. Glang A. Effective Assessment and Instructional Practices for Students with ABI. In: Students with Acquired Brain Injury: The School‘s Response. A Glang, GHS Singer & B Todis (Eds.) Baltimore, MD: Paul H. Brookes Publishing Co, 1997.

Melton A. Bourgeois M. Training compensatory memory strategies via the telephone for persons with TBI. Aphasiology. 19(3-5): 353-364, 2005.

Riley G. Heaton S. Guidelines for the selection of a method of fading cues. Neuropsychological Rehabilitation. 10(2): 133-149, 2000.

Sohlberg MM. Turkstra L. Cognitive Rehabilitation: Teaching New Skills, Strategies and Facts to People with Acquired Brain Injury. New York: Guilford Press. (in press).

Sohlberg MM. Kennedy MRT. Avery J. Coelho C. Turkstra L. Ylvisaker M. Yorkston K. Evidence-based practice for the use of external aids as a memory rehabilitation technique.

Journal of Medical Speech Pathology, 15(1): xv-li, 2007.

Stein M. Carnine D. Dixon R. Direct instruction: integrating curriculum design and effective teaching practice. Intervention in School and Clinic. 33(4): 227-234, 1998.

Swanson HL. Instructional components that predict treatment outcomes for students with learning disabilities: Support for the combined strategy and Direct Instruction Model.

Learning Disabilities Research and Practice, 14(3): 129–140, 1999.

Swanson HL. Searching for the best model for instructing students with learning disabilities. Focus on Exceptional Children. 34(2): 2–15, 2001.

Wilson BA. Baddeley A. Evans J. Shiel A. Errorless learning in the rehabilitation of memory impaired people. Neuropsychological Rehabilitation. 4(3): 307–326, 1994.

Ylvisaker M. Adelson PD. Braga LW. Burnett SM. Glang A. Feeney T. et al. Rehabilitation and ongoing support after pediatric TBI: 20 years of progress. Journal of Head Trauma Rehabilitation. 20(1): 95-109, 2005.

Ylvisaker M. Todis B. Glang A. Urbanczyk B. Franklin C. DePompei R. Feeney T. Maher Maxwell N. Pearson S. Tyler J. Educating students with TBI: Themes and recommendations. Journal of Head Trauma Rehabilitation. 16(1): 76-93, 2000.

About the Authors

Laurie Ehlhardt, Ph.D. is an Assistant Fellow with the Teaching Research Institute (TRI), a division of Western Oregon University. She has conducted research, development, and trainings in the area of evidence-based instruction applied to assistive technology for cognition (ATC) for individuals with acquired brain injury for over 10 years. Dr. Ehlhardt has published a number of papers on the topic of ATC and was lead author on a comprehensive literature review of research conducted in the area of instruction for individuals with ABI. She is also a speech-language pathologist with over 20 years of experience working with adults diagnosed with acquired cognitive-communication impairments due to ABI and working across the continuum of care, including inpatient and outpatient rehabilitation and vocational settings.

Ann Glang, Ph.D. is a Senior Research Professor at TRI. In the past 18 years she has secured and directed or co-directed more than 20 federally funded research projects focused on individuals with ABI. Dr. Glang has been developing training tools for parents and teachers since 1987, including a training program for providing psychosocial support to parents coping with the effects of childhood ABI and interventions to train family members of adults with ABI in advocacy skills. Dr. Glang has also developed computer-based video instruction materials for paraprofessionals working with individuals with ABI. Dr. Glang has published a number of articles in refereed journals, edited two books on her work with children with ABI, and co-authored five manuals for educators serving children and youth with ABI. Patricia Sublette, Ph.D. is an Assistant Fellow with TRI and currently serves as the Traumatic Brain Injury Education Coordinator for the state of Oregon. Trained as a regular and special education teacher and school psychologist, she has worked in public, private and university settings teaching, providing technical assistance and training to adults for last 15 years. Dr. Sublette has co-authored two book chapters and multiple peerreviewed articles on using a neuropsychological approach in schools to serve students with brain injuries and other disabilities.

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Post-Acute Adult Continuing Education after TBI

by Stacy Levesque, M.A. CCC-SLP, CBIS, Justin Moses, CBIS, Hector Gutierrez, CBIST, and Christin Moses Most professionals in the field of post-acute rehabilitation of per- tic approach. Classes were introduced according to relevant topics sons with traumatic brain injury (TBI) agree that cognitive reha- generally affected by traumatic brain injury, as well as, general bilitation is crucial to enhancing these individuals’ lives. Almost knowledge/expertise of staff and/or therapists. Therapists and everything in a person’s life is tied to cognitive functioning and, staff worked together to develop a structure of classes fitting the once debilitated by injury, leaves devastating effects. TBIs, regard- needs and interests of the “students” while also learning how to less of severity, can result in cognitive, psychological, and physi- make each topic a therapeutic experience. Additionally, therapists ological deficits. It is the goal of the rehabilitative team to assess helped class instructors plan and organize their lessons to include and respond to arising issues with deficits in cognition, executive appropriate memory strategies and evaluation techniques that fit functioning, and/or self awareness, which may impede potential the individual’s learning style. Teachers learned how to address gains. It is not unusual for individuals to become depressed and each student’s strengths and weaknesses, as well as how to manfrustrated at their inability to function at their pre-injury level, age and engage everyone in the group. For example, Orientation while at the same time denying any cognitive impairment. In ad- class was developed to engage a person’s Temporal Orientation dition, post-acute continuing education for individuals after TBI for recent events (i.e., current events including political elections, can combine the best of both worlds – cognitive rehabilitation current holidays and festivities, sporting events and scores, etc). A and real-world education. staff member well rehearsed in current events (someone who reads While cognitive rehabilitation usually includes traditional the newspaper daily and or listens to the news) assists each morncognitive intervention delivered by therapists (e.g., speech and ing in running this class. This particular class can cover relevant language pathologists) and/or neurotopics, according to the news, that affect psychologists, such therapy also offers a To see a sample weekly course schedule, their lives. The therapeutic intervention unique programming opportunity, inis built as certain topics are reviewed and visit www.nabis.org/schedule.pdf cluding “post-graduate classes” for educatdiscussions are engaged and/or redirecting individuals with brain injuries. Post-acute adult continuing ed. Teachers are working to engage individuals with knowledge education as described in this article uses the format of a “univer- of local or world events which may assist in improving skills and/ sity type” curriculum uniquely crafted to fit the needs of individ- or decreasing deficits, including the following: general awareness uals with brain injuries. The system provides an inter-disciplinary of events outside of their own lives (decreasing egocentric social approach for improving independent living, new learning, and skills), debating issues appropriately (increasing communication cognitive-linguistic skills. It was demonstrated that individuals skills, flexible thinking) and developing empathy for others. with significant neuro-cognitive deficits, despite severity or time Some examples of the classes that are currently being offered elapsed since onset of injury, made improvements with cognitive with selected objectives include: new learning as seen on standardized testing and subjectively seen 1. Planning and Arrangements Meeting – This course assists by analyzing social and behavioral skills. Participants considered participants with planning their week to include all classes, in this study, included males and females from 18-60 years of age outings into the community, therapies, and individual needs. who were 2-25 years post mild to severe TBI. Specific goals and Staff members assist each person with coordination of activiobjectives were tailored to each individual’s needs for maintainties, as well as allowing participants to focus on goal setting, ing and establishing independence. All therapeutic interventions budgeting expenses, and reviewing accomplishments from the were reinforced by structured programming from 7:30 a.m. to previous week.

9:30 p.m., including four cognitive/social/behavioral classes a 2. Memory Games – The purpose of this course is to learn the day, physical programming at an exercise center, and social outrules of various interactive games, implementation of strateings into the community each evening. Cognitive testing that gies, and how to socially interact accordingly. Different games was performed both pre-treatment and post-treatment assisted in allow participants to exercise many different cognitive abiliconfirming improvements seen in functional daily living skills. ties, including but not limited to: application/generalization The goal of this post-acute program was to create a class strucof abiding rules, processing speed, problem solving, attenture and programming events based upon the premise of a holistion span, multi-tasking, task switching, verbal fluency, topic 14 BRAIN INJURY PROFESSIONAL

maintenance, etc. Gaming with others can teach individuals to handle adversity, respect other’s time, negotiate, lose and win. Gaming is a terrific way to forge friendships and allow extraordinary opportunity to communicate and collaborate with others.

3. Cultures Around the World – This course offers a fun and engaging way to explore our outside world. Participants cover cities, countries, and cultures including topics of food, music, geography, customs, religions, art, systems of education, languages, sports, and much more. Participants are involved in many activities including general lectures, listening to music, tasting the foods, looking at pictures/artifacts, hands on activities, while being able to share personal experiences and stories of their own travels.

4. Memory Jeopardy – This course offers a fun and friendly way to enhance memory skills. Questions are submitted by teachers from all of the classes in order to review information previously shared during the week. Participants recall details of these classes by using the compensatory strategy of note taking and they collaborate by working together on “final answers”.

5. Bible Study – This course allows participants to address real life issues, through inspirational words and stories. Rehabilitation of individuals with brain injury should include training in all of the following: physical, cognitive-linguistic, occupational, vocational, and spirituality. Participants have the opportunity to engage in multi denominational spiritual discussions to grow in healing, grief, and understanding of individuals and others’ spiritual beliefs.

6. Beginning Sign Language – This course enables participants to learn a second language through different senses.

This class is a hands-on approach to learning by allowing participants with increased difficulty with reading, writing, or communication skills to demonstrate knowledge. This course engages a different style of presentation and stimulates visual, spatial and/or tactile learners.

7. Rational Behavior Therapy – This course delivers a methodology for decreasing unwanted behaviors. The objective is to create a direct correlation between positive thoughts to positive outcomes. Changing the way in which a person looks at a situation can create positive solutions even if the situation does not change. Problem solving is merely breaking down situations into steps of how to think and behave in ways to obtain what they want.

These are 7 of the 19 classes available. Others included in the program are History (a window into the past that provides understanding of the present-day, and how individuals, nations, and the global community might develop in the future), Brain Injury Education (a comprehensive lesson in brain injury to assist survivors in understanding their injury), Rosetta Stone (learning Spanish through words and images), Tai Chi (Chinese discipline for health, relaxation, balance, flexibility, strength, meditation, self-defense and self-cultivation), Art Appreciation (self expression through creativity including wood working, sculpting, paper crafts, beadwork, mosaics, etc), Health and Nutrition (general condition of the body or mind, illnesses, or impairments, foods and their effects) Meditation (meditation as a form of therapy to cope with a variety of modern-day health problems, including hypertension, stress and chronic pain), Science (teaching systems and structure, scientific problem solving, and units that may cover any subject, from Solar System to Human Body), Meals on Wheels (reaching out to help others by providing nutritious meals

for people sixty years and older who are homebound and unable to prepare meals). Weekly-Wrap Up (“final review” of participants’ week in detail including review of all materials learned in the weekly classes to increase immediate and recent memory with repetition), and Problem Solving for Life (task analysis within a structured setting as well as out into the community for functional problem solving skills). These classes are offered throughout the week at 10am class, 11am class, and a 4pm class, along with Orientation every morning at 9:30am. Participants have other structured activities including 8am stretch and 1 mile walk, 2:30pm community outing to the YMCA, and another social activity for community integration at 7pm. Individuals may choose to join the group for evening outings including: Mondays for Library, Tuesday for Arts-N-Crafts, Wednesdays to Billiards, Thursdays to Bowling, Fridays to Bingo/Golf, Saturdays for a Movie on or off the grounds, and Sunday to a local festival or community activity.

Many lessons and skills are learned in each class. The classes consist of activities that are meaningful to both the participants and the therapists/teachers. The participants help choose the topics and the therapists develop a method to make it a learning experience for all involved. Each class was developed with an individual theme in mind. For example, during Listening Comprehension class, participants can take turns picking a musical artist that they would like to study. The teacher finds songs where the lyrics are meaningful and will engage in an appropriate discussion. The class learns information about the artist/band history for cognitive recall. They read lyrics for increasing reading comprehension and abstract meanings, and they listen to the song for fun and dancing. Flexibility in participation is important to keep everyone active. Therapy or constructive activities occur in a structured group setting thus allowing the participants to accomplish their programming objectives. Various individualized therapeutic activities occur during class time. Some participants are active in class while some may be grocery shopping (constructive activity) and another may be seeing the therapist.

Therapists can arrange their schedules to pull out certain participants during a particular class that may not be as beneficial as their therapeutic intervention. For example, a person with less anger/behavioral issues may be better suited to see the Physical Therapist (given physical needs) during Rational Behavioral Therapy while others are learning the difference between rational and irrational thoughts.

All topics are arranged in a format that encourages cognitive learning, communication building, and social pragmatic independence. Cognitive learning occurs during the classes as participants learn different facts about different subjects. They are required to learn information from each class, and they are encouraged to rehearse the materials using as many memory strategies as possible. Teachers use both intrinsic memory strategies, as well as, journaling for compensatory usage. Participants, after learning the materials in a class, rehearse the information in many different ways to maximize their learning. Participants recall their activities on a daily basis, and they are accountable for weekly recall and monthly demonstration of knowledge. Participants are asked to maintain a daily journal with details, listing all structured and unstructured activities. They are required to recall their day with or without a compensatory device twice daily.

Participants sit down with staff members during the afternoon and after the evening activity to review and reinforce what they have learned and recall from that particular day. This allows participants to get paid in tokens for their daily efforts as well as review strengths, weakness, and goals met for the day. Participants BRAIN INJURY PROFESSIONAL

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attend weekly recall sessions, Weekly Wrap Up and Memory Jeopar- testing. Therapist/teachers look at the individual’s base of infordy. The Weekly Wrap Up class allows individuals the opportunity mation going into a discussion about a topic from past knowlto review their notebook and recall each activity throughout the edge and then what they will be learning. Therapists/teachers week as a group activity and take turns discussing the material are aware of a person’s memory skills and the rate in which they that they learned in each class. Each participant verbally commu- generally learn something new. Some of the participants have litnicates the details within their journal or a fact about the subject. tle education, but they possess the ability to learn quickly. Other Many are very proud to elaborate on different facts that they have participants have high education but need maximal assistance learned. After a fact is given from each person, the entire les- with memory. As they teach the lesson, therapists and teachers son may have been reviewed. Memory Jeopardy gives individuals can determine whether a person demonstrated a correct answer the opportunity to recall information in a competitive game-like on a test because of long term memory or if the information was setting. Each teacher provides 5-10 questions from his/her class recently learned.

Teachers work with therapists to make class cognitive-linand participants work together to come up with the final answer.

Competition for winning the game adds an entirely new concept guistic objectives fitting for each individual. Some individuals are learning basic concepts of jourfor learning. Some individuals may naling (i.e. learning to summarize be motivated extrinsically by comimportant facts, who, what, etc), petition when insight into deficits while others are generalizing conor awareness of subject importance cepts from all classes. When a permay be lacking. For example, particson learns the material, they may ipants might not have thought they become assistant group leaders or a needed to go to Brain Functioning role model for others. Participants Education (learning about the lobes truly “own” the material when they of the brain, each lobe’s functionare capable of teaching the material. ing, or what happens after traumatic This usually opens up an entire area injuries), but they may go only in to work with a client on social skills, anticipation of winning the game of empathy, deliverance of material, Memory Jeopardy. Both groups aletc. low participants to be challenged to Objectives involve more than recall information from lessons that working within the cognitive frameweek, as well as, an opportunity to Stacy Levesque, M.A. CCC-SLP, helps work. Social objectives are being listen and review information being Joshua Ashley with his journaling. met in every class and reinforced presented.

Lastly, teachers provide “tests” at the end of a unit. The by the staff as well as the therapists. It is important to use sevparticipants are given non-standardized tests in each class unit eral approaches and situations when teaching social skills. Social and are expected to demonstrate knowledge without compensa- skills are difficult to teach because the dynamics of a conversation tory devices, so that teachers can measure true learning (owning changes rapidly and the person is expected to be flexible. One can and producing back the information by some demonstration of role play situations for examples, but one conversation does not knowledge). Each teacher formats a test for best retrieval of in- necessarily generalize. Different communicative partners or difformation taught in class. For example, a teacher in the Around ferent conversation topics add variables that allow one particular the World class may do a unit on Mexico (cultures, foods, reli- social skill difficult to master. For example, someone who is workgions, languages, etc). After studying the country for a month, ing on not interrupting others can work on this particular social learning facts, tasting or cooking foods from their culture, lis- skill in all the different classes where the conversation topics and tening to music, etc), they may be asked specific cognitive ques- group members are constantly changing. It is important for that tions about examples of food, names of regional music, and/or individual to experience many subjects to master the social skill how their country differs from ours. Tests may consist of fill in because they may or may not interrupt depending on the subject the blank, multiple choice, or matching questions. The entire matter. The person can get feedback from multiple sources, rather learning system includes hearing the material in class, expound- than disregarding the Speech Therapist’s wishes. Communication ing upon it during subsequent classes, and reviewing the same skills being worked on in every class include some of the followmaterial in daily recall sessions. In addition, it is recalled again ing: initiation of interaction, topic maintenance, turn taking, weekly during Weekly Wrap and Memory Jeopardy, and monthly content relevance, eye contact, facial expressions, and non-verbal/ by demonstration of knowledge on a test. Individuals constantly body language. Different classes offer individual speech tasks, group discussions, as well as, group role plays. Many participants have the opportunity to build upon their initial learning.

All topics can be a cognitive-linguistic challenge for all indi- can be working on different social skills on multiple severity levviduals involved no matter what the level of injury, pre-existing els. One individual is working on not “butting in” while a difeducational level, and/or ability for new learning. All individuals ferent individual may be working on a higher level social skill by can walk away LEARNING information, despite pre-conceived assisting the instructor to teach the class; therefore, working on notions that it is difficult to educate persons of different capabili- class management and delivery (how to engage peers, summarizties within one environment. Information is taught on a variety ing material in an appropriate manor, being a role model, etc).

Every person can be engaged both cognitively and socially of subjects. It is challenging for most individuals to learn information within 8-10 different subjects. There are some classes that when there are many opportunities for learning. Repetition is a are naturally more challenging for individuals and other subjects memory strategy that is both used within the structure and durthat come easier to them. Scores on tests are considered compa- ing classes. Multiple opportunities for learning provide positive rable to expectation levels from their individual’s initial cognitive results in both cognitive and linguistic skills.

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The California Verbal Learning Test Second Edition Short Form (CVLT-II SF) was used to assess participants’ ability to learn and remember verbal information. It not only assesses the amount of verbal information remembered, but how verbal learning occurs or fails to occur. The CVLT-II SF is designed for examinees with more severe cognitive dysfunction, as compared to the CVLT-II Standard Form. This test was given after one year of participating in the highly structured class setting. Participants were given a standardized score based upon their age group, and the mean standard scores of all 12 participants, compared from 2008 to their mean in 2009. For all recall scores, the higher the values indicate better performance. Exceptions to this are the different error measures (i.e. repetitions, intrusions, & false positives). Trial 1 Free Recall measures the examinee’s initial auditory attention span, repeating a list of 9 words. Standard scores are derived for each trial following to assess the consistency of an examinee’s learning performance over repeated trials (i.e. distractibility, fluctuations, varying effort, or other non-neurological factors).

Trials 1-4 index provides a global measure of immediate free recall performance. Short Delay Free Recall provides a measure of an examinee’s level of recall after a brief delay interval by asking the examinee to recall the same list after counting backwards by 100 for 30 seconds. Long Delay Free recall provides a measure of an examinees’ level of recall after a 10 minute, non verbal distraction task. The Long-Delay Cued Recall subtest requires the examinee to recall the same list initially presented, but within defined categories and the Long Delay Yes/No Recognition assess recognition of the words with distracter words intermixed. After another five minute, non-verbal distracter task, the examinee is then asked on the Long-Delay Forced Choice Recognition to choose which word out of a choice of two was on the list. Repetitions, intrusions, and false positives measure a person’s source memory impairment with increased numbers indicating increased difficulty with insight of what is true and/or untrue.

A statistical summary of performances of all examinees showed improvements in the overall majority of tested variables.

A one-tailed dependent T test was performed to examine the significance of the difference in scores between the pre and posttests.

The alpha value was set at 0.05. The change in scores for Trials 1 – 4, Short Delay Free Recall, Long Delay Free Recall and Long Delay Cued Recall was found to be significant. The Long Delay Forced Choice Recognition and the Long Delay Yes/No Recognition, changes were not found to be significant. It needs to be noted that most participants in the Long Delay Force Choice and Yes/No Recognition initially tested, showed high scores, and were subsequently not able to increase. Intrusions, false positives, and repetitions all declined; however, the changes were not seen to be significant. Additional statistical tests were completed, the results of those tests coincided with the findings of the current tests.

Overall, it was determined that standardized test scores for new learning improved for the majority of participants following one year of participation in a highly structured curriculum based residential brain injury facility. On the standardized testing, individuals were able to make improvements with their initial auditory attention span, consistency of learning performance over repeated trials (i.e. distractibility, fluctuations, varying effort, or other non-neurological factors), global measure of immediate free recall performance, recall after a brief delay, recall after a 10 minutes, and recalling the same list initially presented, but within defined categories. The decrease in repetitions, intrusions, and false positives assisted with increasing insight into responses and decreasing an individual’s tendency to confabulate

from source memory impairments, as well as, seeing changes on a standardized test, teachers, therapists and staff members alike agree to social and linguistic changes seen over the course of the year. On a whole, subjectively noted, there were less overtly negative behaviors with the antecedent of confusion. Social skills were being met on a multitude of levels. Insight into memory skills and social skills were being taught extrinsically as an individual could perceive themselves succeeding in competition for Memory Jeopardy and within constant debates during class room discussions. When therapists attempt to give examples of social skills they have concrete examples to use in discussions so the participant can directly relate an issue to an example. Therapist and Program Directors assisted in creating objectives for individuals, and the participants were reinforced by multiple situations and multiple persons, giving increased chance of success.

This system employed provides an inter-disciplinary approach to improving independent living, new learning, and cognitivelinguistic skills. Individuals with significant neuro-cognitive deficits, despite severity and time elapsed, made improvements seen on standardized testing and also subjectively seen with social and behavioral skills. Specific goals and objectives were tailored to each individual to meet their needs for maintaining and establishing independence. Therapeutic interventions are reinforced by four cognitive/social/behavioral classes a day, physical programming at the YMCA, and social outings into the community each evening. Cognitive testing was performed both pretreatment and post-treatment, and these assessments assisted in confirming improvements in functional daily living skills. The strategy and goals of rehabilitation must pivot around the axis of self identity. In defining and establishing true-self identity, one finds the keys to guide satisfying work and establish meaning for the living of one’s life. The tools for living are unique, and once lost, they need replacing. A structured curriculum helps that individual step beyond his or her limitations. The model of intervention inclusive of all insightful domains builds bridges for our clients to obtain dignity, self-respect, redefinition, and active participation. It is an innovative approach to address the holistic needs of individuals, critical real life issues (not just medical needs) and addresses the core of what makes a person “alive”.

About the Authors

Stacy Levesque, M.A. CCC-SLP, CBIS, is a Speech-Language Pathologist for NRLCL. Her direct experience is with cognitive-linguistic deficits, social skills training, and behavioral disorders has assisted with development of the Post-Acute continuing education “University” curriculum. Ms. Levesque is a member of Brain Injury Association-Louisiana (BIALA) as well as North American Brain Injury Society (NABIS).

Justin Moses, CBIS, is the Program Director of NRLCL. Mr. Moses has been assisting with directing rehabilitation centers for 7 years. Mr. Moses, while at NRLCL, has created a staff training system that provides the staff with the tools and resources to assist in running one of the most active postacute rehabilitation centers in the Southern United States. Mr. Moses is a member of Brain Injury Association-Louisiana (BIALA) as well as North American Brain Injury Society (NABIS).

Hector Gutierrez, CBIST, is Executive Director at NRLCL and is currently a partner with Dr. Robert Voogt at NRLCL in Covington, LA. Mr. Gutierrez has been working in the brain injury field since 1976. Mr. Gutierrez directed an adolescent program for Mary Lee Foundation in the late 1970s, and was the Clinical Director to the Tangram Rehabilitation Network from the early 1980’s to 1998 and the Regional Director to ResCare’s brain injury programs from 1998 to 2003.

Christin Moses received her Bachelor of Science from Texas Women’s University. Ms. Moses is currently the Clinical Coordinator at Nuerological Rehabilitation Living Centers in Covington, LA. Ms. Moses coordinates the clincal and administrating programs.

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18 BRAIN INJURY PROFESSIONAL

Restore-Ragland

Restore-Roswell

Restore-Lilburn

Restore Neurobehavioral Center is a residential, post acute healthcare organization dedicated exclusively to serving adults with acquired brain injury who also present with moderate to severe behavioral problems.

Services range from intensive inpatient neuro-rehabilitation and transitional community re-entry services to long term supported living services. Restore Neurobehavioral Center, located in a suburb north of Atlanta, is the site of our inpatient post acute neuro-rehabilitation program as well as one of our supported living sites. We operate two other community living sites, Restore-Lilburn (GA) and Restore-Ragland (AL).

www.restorehealthgroup.com 800-437-7972 ext 8251 drug & alcohol treatment for adults with disabilities

Highly-individualized alcohol and drug treatment program characterized by adaptation to learning styles, frequent oneon-one counseling sessions, and slower-pace with frequent repetition.

Phone 763.479.3555 www.vinlandcenter.org BRAIN INJURY PROFESSIONAL

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The Pediatric Acquired Brain Injury Plan

Roberta DePompei, PhD

In the past twenty years, several reports and articles have outlined recommendations for how to ensure smooth transitions for children and youths with brain injury (Ylvisaker et al., 2005; Ylvisaker et al., 2001; Savage, DePompei, Lash, & Tyler.

2005). Various national agencies and organizations such as the Brain Injury Association of America (2008), Center for Disease Control and Prevention (1999), National Institute on Disability Rehabilitation Research, and Health Resources and Services Administration have also advocated for the needs of this population.

However, without a comprehensive national initiative and funding, little coordinated progress has been made.

In January 2009, the Sara Jane Brain Foundation brought 50 researchers, clinicians, and family members together and issued a challenge to develop a national plan of care for children, adolescents, and young adults with brain injuries. Within one month, a national Pediatric Acquired Brain Injury Plan (PABI Plan) (Sara Jane Brain Foundation, 2009) was created.

The PABI Plan outlines seven Categories of Care for treating brain injuries in children, adolescents, and young adults. It also establishes a lead center in each of the fifty states. Each center will work within all seven categories of care while being a specified center for one of the seven. There will also be seven national lead centers, one for each Category of Care. Figure 1 is the national plan schemata.

The seven national lead centers and the lead centers for each of the fifty states are listed in the PABI Plan. The seven Categories of Care and the responsibilities of the Centers include: 1. Prevention: The Centers will emphasize the three levels of prevention — primary (forestalling TBI), secondary (limiting the impact of TBI), and tertiary (preventing repeat brain injury). The Centers will locate existing prevention programs that are effective and help disseminate them nationally. If needed, existing organizations will be assisted to develop and distribute new evidence-based prevention programs.

2. Acute Phase: The Centers will seek to standardize acute care for TBI — field-side assessment, emergency department triage and stabilization, critical and acute care management in hospitals, and rehabilitation — based on state-of-the-art 20 BRAIN INJURY PROFESSIONAL

evidence. This standardized approach will comprise all areas of healthcare delivery and healthcare personnel education and training. In addition, the Centers will investigate the timing and efficacy of rehabilitative interventions in the care of children and young adults with TBI. Communication with families will be considered essential to seamless transitioning among all community agencies for the remainder of the child’s life.

3. Mild TBI Assessment and Treatment: The Centers will develop and disseminate methods to identify this undiagnosed and untreated population. They will develop programs for specialty outpatient clinics for active treatment and management. This program will also study how to develop and staff clinics with trained personnel and provide methods to decrease the number of clinical problems that children and families face post-injury.

4. Reintegration and Long-term Care: The Centers will address the many aspects of transition from medical facilities to schools and community reintegration through education and research. The Centers will help local communities diagnosis and treat appropriately, facilitate recovery, stimulate learning and socially acceptable behavior in schools, and enhance participation in the community. They will also assist in the adequate provision of services to severely injured patients Figure 1

who need lifelong care.

5. Adult Transition: The Centers will determine how to provide a seamless transition into the adult system of service and care for individuals, caregivers, educators, and the community.

Aspects to be emphasized include independent living, vocational training, and education after high school, leisure, and quality of life.

6. Rural/Telehealth: The Centers will develop a system of care universally accessible to children and young adults and their families no matter where they live in the nation. They will emphasize methods for reaching families living in rural America, which encompasses over 75% of the landmass in our country and almost 25% of the population. Telehealth and telerehabilitation programs will be developed, tested, and implemented throughout the country by enhancing those that exist and developing those that are needed.

7. The Virtual Centers: These Centers will establish a nationwide standard for collecting translational data, a standard set of training and education information easily accessible to all, and will help other centers use technology to develop basic science research and disseminate results for each category of care. In addition to serving as a data collection pool, the Virtual Centers will act as online resources for individuals, families, professionals, and the general public at all stages on the continuum of care.

The extent and scope of the PABI Plan are ambitious, and the results remain to be seen. Several benefits have already emerged, however. First, there is a comprehensive plan, agreed upon by key researchers and clinicians, representing best practices. The major issues and an aggressive plan to address them are clearly outlined for the public. Second, each state has a stake in the development, implementation, and benefits of this plan; thus all states should support it. Third, ideas for funding through federal and state grants are well outlined in this document, and it can serve to direct and justify future research initiatives. Finally, any organization or agency can use this plan to implement its own programs for this population.

About the Author

Roberta DePompei, PhD, is a distinguished professor and director of School of Speech-Language Pathology at the University of Akron. Her major area of research and interests is in cognitive and communication challenges for people with brain injuries, specializing in the effect of brain injury has on speech, language, communication and learning. Dr. DePompei is on numerous national task forces and committees, as well as co-chair of the Special Interest Group on Children and Adolescents with Brain Injuries for the Brain Injury Association of America.

References

Brain Injury Association of America. A call to action for children and adolescents with Traumatic Brain Injury. TBI Challenge. Washington, DC: BIAA. 2008; 2–4:17.

Centers for Disease Control and Prevention. Traumatic Brain Injury in the United States: A Report to Congress. 1999. Retrieved from http://www.cdc.gov/ncipc/tbi/tbi_congress/index.htm.

Savage R, DePompei R, Lash M, Tyler JS. Pediatric traumatic brain injury: Review of pertinent issues. Pediatric Rehabilitation. 2005; 8(2):92–103.

The Sarah Jane Brain Project. National Pediatric Acquired Brain Injury Plan. 2009. Retrieved from http://www.thebrainproject.org.

Ylvisaker M. Adelson PD. Braga LW. Burnett SM. Glang A. Feeney T. et al. Rehabilitation and ongoing support after pediatric TBI: 20 years of progress. Journal of Head Trauma Rehabilitation.

20(1): 95-109, 2005.

Ylvisaker M. Todis B. Glang A. Urbanczyk B. Franklin C. DePompei R. Feeney T. Maher Maxwell N. Pearson S. Tyler J. Educating students with TBI: Themes and recommendations. Journal of Head Trauma Rehabilitation. 16(1): 76-93, 2000.

BRAIN INJURY PROFESSIONAL

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Coastline Community College

by Celeste Ryan, ms, Michelle Ranae Wild, ma, and Sandra P. Klein, phd

in increasing awareness and acceptance of who s/he is now, post-injury. The class has two components: Processing and Curriculum. During Processing, students have the opportunity to process or problem-solve appropriate material in a group setting with feedback from staff members and peers. The Curriculum component of Psychosocial class is divided into four specifically designed units relating to brain injury. Specialized topic-specific workshops have also been developed by the psychosocial team to address a variety of adjustment issues.

Participation in the program has proven to be “life changing.”

As one alumnus wrote: “I graduated in 2002. I am now happily married and finishing up a Master’s in Psychology with an emphasis on marriage and family development. I was hit by a car 7½ years ago, spent two months in a coma, and suffered a traumatic brain injury. I would not be where I am today without the cognitive retraining that I received at Coastline. For that I am very grateful. Coastline’s ABI Program is an excellent and necessary program….”

Educational Program The educational component of the ABI Program continues Students attend the ABI program four hours a day, four days to evolve, based on the needs of the a week. Each day consists of cognitive “A drunk driver changed the course of my students. More recent enhancements and psychosocial components. The life, and this program has given me the to the program include the integration cognitive component of the program consists of three 50-minute classes: tools to make this new journey livable and of a comprehensive Future Planning curriculum (adapted from Moving On, Concepts, Application, and Computer manageable.”

A Personal Futures Planning Workbook Lab. Concepts class exposes students to sponsored by the Research and Training Center on Community a particular cognitive skill area (e.g., figural analogies or some Integration of Individuals with Traumatic Brain Injury, The aspect of critical thinking) and incorporates group discussion Mount Sinai Medical Center) to better prepare brain injury and reference to possible applications of the skill. During survivors for life after brain injury.

Students begin thinking Application class, students apply the cognitive skill introduced about their transition plans at the beginning of their second during Concepts to “real life” scenarios and activities. Similarly, semester in the program by attending their first Future Planning Computer Lab provides students with the opportunity to apply group.

A workbook helps guide each student through important and practice cognitive skills, utilizing cognitive-retraining software, word-processing programs, or other software programs steps to “map out” their plans for the future. Twelve “mental adapted for the purpose of building cognitive skills (e.g., maps” are completed by each student over a two-year period.

Students discuss their responses in a group setting where they Microsoft OneNote, Inspiration).

Psychosocial class meets for one 50-minute period each day. receive feedback from both peers and instructors. At the one-year The primary goal of Psychosocial class is to aid each student mark, each student begins meeting individually with a Transition Coastline Community College has a long history of providing high-quality cognitive retraining for adults living with brain injury. In fact, Coastline established the nation’s first community college-based brain injury program in 1978. The Acquired Brain Injury (ABI) Program is a demanding, twoyear educational program designed to provide cognitive and psychosocial retraining for adults who have sustained a brain injury due to traumatic or atraumatic injuries. Students who participate are involved in a structured educational program that includes cognitive retraining, psychosocial skills development, counseling, testing, and transition planning. Offered as a component of the college’s Special Programs and Services Department, students pay the traditional low-cost community college fee; out-of-state students are subject to non-California resident policies and tuition. The program serves more than 200 students annually.

22 BRAIN INJURY PROFESSIONAL

Specialist. The individual meetings are designed to help students stay on track and set goals to begin working toward their future plans before they graduate from the ABI Program.

To provide students with additional support tools and strategies, training related to the use of Windows Mobile and iPod Touch/iPhone PDAs and smartphone devices as memory/ cognitive prosthetic devices was introduced to students at all cognitive levels. The training approach teaches the fundamental technical skills necessary to operate a PDA/smartphone while simultaneously drawing a parallel to the cognitive skills that underlie the development of those technical skills. Focusing on the cognitive skills required to use the device and then having the users apply those same cognitive skills to their everyday lives makes this approach practical, concrete, relevant, and transferable.

In addition to the main four-day-per-week ABI Program, the department offers a variety of other classes and services. All ABI students are required to attend a series of afternoon career development classes in which they identify career and community transition options and develop goal-setting and job search strategies as part of a transition plan. After graduating from the ABI Program, many students find that a review of compensation strategies is helpful for continued success. Coastline’s ABI Program offers a Refresher class once a year during the Spring Semester; the class meets for two hours once a week for six weeks.

Topics such as memory, organization, and problem-solving are reviewed and strategies discussed. For students who have sustained a brain injury but who remain in school or employed full-time, the college offers a Mild Head Injury Program in which students work individually with a cognitive instructor to identify deficit areas and develop compensatory strategies.

The newest addition to the educational programs offered

by Coastline is an exciting online program – the Cognitive and Caregivers Boot Camp. This unique online program is designed for individuals living with TBI as well as for professionals, paraprofessionals, caregivers and significant others. The online program emphasizes evaluation of cognitive skills, development of strategy building to compensate for cognitive difficulties, psychosocial adjustment and community integration. In addition, information regarding support, resources, and strategies for coping with changes experienced after an individual sustains a brain injury are discussed throughout each of the four online courses.

Outcomes

Since the inception of the program, collection of pre- and posttest measures has been used to evaluate the effectiveness of the program. In 2006, the Neuropsychological Assessment Battery (NAB) was adopted as the program’s primary measurement tool.

Preliminary results suggest significant improvements in pre/post evaluation on the Overall Cognitive Functioning-Total Screening Index as well as in the Screening Memory Domain, Screening Spatial Domain and Screening Executive Functions Domain.

In addition, significant improvements were indicated on the Attention Index Module and specific Activities of Daily Living (ADL’s). ADLs that were significantly improved included Daily Living Memory-Immediate, Daily Living Memory-Retention, Daily Living Memory Recall versus Recognition, Daily Living Memory-Delayed Recall, and Map Reading.

About the Authors: Celeste Ryan, MS, and Michelle Ranae Wild, MA, are Co-Department Chairs for Coastline Community College’s Acquired Brain Injury Program. Both have more than 30 years of experience in the program and in the field of brain injury. Ms. Wild has written many books on the use of PDA/smartphone as a memory compensation tool for individuals with brain injuries. Sandra P. Klein, Ph. D. has been affiliated with the program since 1989 and currently serves as the Clinical Psychologist and Consulting Neuropsychologist to the program. Dr. Klein is also an Adjunct Professor at Alliant University in Irvine, California, teaching graduate level Neuropsychological Assessment.

For more information visit http://abi.coastline.edu or call (714) 241-6214.

Services

Coastline’s Special Programs and Services for the Disabled department offers a variety of services including individual counseling. Students are afforded the opportunity to process personal issues and develop coping skills working one-on-one with a counselor. The counseling staff consists of one full-time counselor, who is a licensed Marriage and Family Therapist (MFT) and a consulting neuropsychologist, who supervises four to six doctoral or master’s level interns.

In addition, an alumni group is available to graduates of the program. This group provides alumni with the opportunity to socialize, share experiences and support one another. Alumni also serve as mentors, participate in the orientation of new incoming students, and join forces with the program’s Foundation Board to raise funds to support students in need and to purchase materials and services not otherwise funded.

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Pennsylvania’s BrainSTEPS: Child & Adolescent Brain Injury School Re-Entry Program

By Brenda Eagan Brown, MSEd, CBIS Each year, approximately 4,000 of Pennsylvania’s children survive severe traumatic brain injuries significant enough to require hospitalization. (Pennsylvania Health Care Cost Containment Council’s Hospital Discharge Data, 2004 & 2006). Many are left with life-altering difficulties in physical, cognitive, or behavioral function. In order to meet the needs of these children as they re-enter school, The BrainSTEPS (Strategies Teaching Educators, Parents, and Students) Child & Adolescent Brain Injury School Re-Entry Program was developed. It is supported through Federal Title V Maternal and Child Health Block Grant funding to the Pennsylvania Department of Health, developed and implemented by the Brain Injury Association of Pennsylvania (BIAPA), partnered with the PA Department of Education. BrainSTEPS is working to ensure that those who provide education to children following brain injury have an understanding of that injury, the resulting challenges, and the interventions and supports necessary to help those students achieve educational success through graduation. The BrainSTEPS Program was adapted from brain injury school reentry programs existing in Kansas and Oregon, using the model of creating and training teams across the Commonwealth to provide consultation to schools in their local areas to meet the needs of students with brain injury.

BrainSTEPS consulting teams are comprised of professionals in the field of education, medical rehabilitation professionals, and family members. Team members receive extensive training related to the educational needs of children with brain injury through an initial training of 30 hours, followed by subsequent annual trainings. Experts on pediatric brain injury are incorporated into annual trainings to further enhance the knowledge base of team members on specific topics, such as executive function, development of cognitive strategies, and management of challenging behaviors.

The BrainSTEPS teams are aligned with the statewide Intermediate Units in the Pennsylvania Department of Education.

Teams serve students with all forms of acquired brain injury, at 24 BRAIN INJURY PROFESSIONAL

all levels of severity, from concussion through severe brain injury.

BrainSTEPS focuses not only on school re-entry following injury, but also provides services to students in the school system who were previously identified as having a brain injury. Teams follow students from referral to the program through high school graduation.

As each Intermediate Unit has some uniqueness in organization, and teams need to fit within the existing infrastructure of that entity, there are some differences in the way teams operate. However, BrainSTEPS Best Practices, created jointly by the BrainSTEPS Program and the Pennsylvania Department of Education, guide the process for providing services. The Program Coordinator, who is employed by BIAPA, develops trainings, works with individual teams to build infrastructure, mentors team members, and guides the process of delivering services as needed. Each team has a 1-3 team leaders who facilitate monthly team meetings in their region to review referrals and develop a plan for providing services to students. The Program Coordinator holds monthly teleconferences with team leaders to assist in development and idea sharing, and holds an annual meeting for team leaders to evaluate program effectiveness and opportunities to improve the program based on successful experiences within each intermediate Unit team. The Program Coordinator also provides consultations to individual teams on a regular basis by attending team meetings or providing collaboration on specific cases.

All of Pennsylvania’s Children’s Hospitals and pediatric rehabilitation facilities are informed about the BrainSTEPS program and are involved in a variety of ways: providing staff to serve as team members; including program referral information in emergency department, trauma department and rehabilitation discharge information; and assisting with team trainings. Currently over 30 partnerships between community agencies and the BrainSTEPS Program have been forged statewide. More than 20 of those partnerships have resulted in team membership.

The BrainSTEPS Program has trained 24 consulting teams

across Pennsylvania, comprised of 250 team members. Over 90 percent of the Commonwealth is served by BrainSTEPS teams.

To date, BrainSTEPS has provided educational presentations on brain injury to 8,000 individuals who come in contact with students with brain injury in Pennsylvania, including school psychologists, school nurses, administrators, teachers, coaches, athletic trainers, and acute hospital and rehabilitation professionals, among others. To determine a systematic way of documenting services and program outcomes, the Pennsylvania Department of Education, in conjunction with BrainSTEPS, created the ORBS (Online Reporting BrainSTEPS) database, www.brainsteps.net.

This online database tracks students in the BrainSTEPS program over time, including changes in educational supports that take place during the teams’ intervention, documents the work of each team, generates reports to summarize the data collected, and serves as a repository for materials that team members can access and share.

BrainSTEPS teams have provided active consultation to nearly 300 students in the past two years. Most referrals have been made by schools (37%) and family members (27%), but referrals can be made by anyone who works with the students in some capacity. The majority of students referred have brain injuries of traumatic etiology (69%) and of those 49% were students experiencing post concussive syndrome effects. BrainSTEPS teams have provided over 1500 individual consultations, including such activities as participating in educational planning meetings; performing student observations; providing input into strategy development and implementation; providing peer education; and communicating with families, medical professionals and school personnel. Future goals of the BrainSTEPS Program

We make it easier to understand, help, treat and live with brain injury in children, adults and veterans.

include development of new teams; ongoing facilitated training of team members to further develop expertise; and implementation of satisfaction surveys for families, students, and school personnel as a measure of program quality. BrainSTEPS is currently working on expansion into post-secondary education, through funding from a HRSA grant. The goal is to train university disability support services professionals on the needs of students with brain injury, and to incorporate them into the BrainSTEPS teams to facilitate a smooth transition to college for students with brain injury.

In December 2008, the Brain Injury Association of America honored the BrainSTEPS Program with a National Award for Excellence in Programs and Services. For more information about Pennsylvania’s BrainSTEPS Program, contact Brenda Eagan Brown, Program Coordinator at eaganbrown@biapa.org.

Reference

Pennsylvania Health Care Cost Containment Council’s Hospital Discharge Data, 2004 & 2006.

About the Author

Brenda Eagan Brown is the statewide Program Coordinator for the Pennsylvania BrainSTEPS Program. She serves on the international advisory board of the Sarah Jane Brain Foundation and is a Certified Brain Injury Specialist through the Academy of Certified Brain Injury Specialists.

Brenda received the Pioneer in Brain Injury Award from the Brain Injury Association of Pennsylvania in 2009. She was also the 2009 recipient of the Wittenberg University Alumni Citation Award. Brenda’s brother sustained a severe TBI in 1987. This led to her actively consulting with schools and families regarding brain injury and resulting educational effects since 1995.

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Elvin DVD An educational DVD to teach elementary age children about brain injury.

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bip expert interview Questions from Parents about School when a Child has a Brain Injury About Marilyn Lash, M.S.W. With over 35 years of experience working with persons with disabilities and their families in medical, rehabilitation, educational and vocational settings, Marilyn Lash’s primary interests are supporting families and developing community programs. She is a founding partner of Lash and Associates Publishing/Training in Wake Forest, NC. Ms Lash is also an Assistant Clinical Professor in the Department of Physical Medicine and Rehabilitation at Tufts University School of Medicine. She is former Chairperson of the Board of Directors of the Brain Injury Association of North Carolina and the current Chair of the Brain Injury Advisory Council for North Carolina.

Because of her experience and expertise in working with families of children with brain injuries, parents often turn to Marilyn Lash for advice regarding school issues following their child’s brain injury. In this interview, Ms. Lash is asked to address some of the most frequently asked questions she receives from parents.

Will my child receive special education because of the brain injury?

The category of traumatic brain injury was added under the federal education act in 1991 (Individuals with Disabilities Education Act). The category is used in all states. However, the diagnosis of a traumatic brain injury does not automatically qualify a student for special education. Once a referral for a special education evaluation has been made, the school conducts a comprehensive assessment to determine the effects of the brain injury upon the child’s abilities to learn and function in school. Each state has specific requirements that the child must meet to be eligible for special education. It is very important for a parent to obtain the Handbook or Rules on Special Education in their state. Any Special Education Director or School Principal can advise a parent on how to obtain this information.

The internet is also a great resource for gathering information by searching with key words such as your state, Department of Education, special education or exceptional children.

Why aren’t more students with brain injuries identified for special education?

It has been a frustrating contradiction for many clinicians, families and advocates that despite the fact that traumatic brain injury is the leading cause of disability among children, they are considered a low incidence population by the US Department of Education. This is reflected in low number of students receiving special education services under the classification of traumatic brain injury in every state.

Unfortunately, the link between an earlier injury to the child’s brain and emerging cognitive and behavioral challenges in school is often missed. Many factors contribute to this including…

• • • •

Ineffective transition planning between medical and educational systems Limited training and experience of educators with this population Inadequate screening and history taking to identify a previous TBI Latent effects of brain trauma mistakenly attributed to emotional or behavioral disorders • Misidentification of cognitive changes as attention disorders or learning disabilities.

Does it make any difference what category is used as long as my child is found eligible and receives special education services?

The simple answer is YES. Before the change in the education law, many students with brain injuries were incorrectly described as mentally 26 BRAIN INJURY PROFESSIONAL

retarded, learning disabled, or emotionally disturbed. Even today, many students are inaccurately classified as a learning disability or attention disorder when in fact they have an undocumented brain injury. The school may be unaware of the child’s history of a brain injury unless it is accurately recorded in the school records and reported by the parent.

The classification of traumatic brain injury for special education helps educators recognize the condition and its consequences. They can then develop educational strategies and programs that are individually designed for that student. Because the full consequences of a traumatic brain injury may not be apparent for many years, the TBI classification helps educators recognize the latent effects that often become apparent as the child’s brain matures and school work becomes more complex.

If the school has no experience or training in brain injury, how can they know what my child needs and how to teach my child?

In an ideal world, every teacher would learn about brain injury in their college curriculum and continue to receive on the job training throughout their career. Despite innovative outreach efforts in many states to increase the knowledge base of educators about brain injury, many schools do not consider it a priority until a student is identified in a local school.

There are many resources to help teachers develop individualized educational programs with teaching strategies and compensatory techniques that can help students with brain injuries. Many of these strategies are already in the classroom teacher’s repertoire. The knowledge base is only part of the picture of what’s important. Experienced parents report that it is a teacher’s willingness to learn about brain injury, to include parents in the planning process, to be flexible and open to new strategies, and to consult with experts on brain injury that can make a difference in developing their child’s educational program.

The special education system is so confusing and new to us since our child’s injury, how can we possibly know what is best for our child?

The special education process may seem overly bureaucratic and complex to parents who are unfamiliar with the process and regulations. However, state and federal education laws guarantee parents certain rights and responsibilities in this process. It is important for parents to know their rights under these laws and to be involved. An excellent place for parents to start is the National Information Center on Children and Youth with Disabilities. This federally funded national clearinghouse provides fact sheets and guides that are written just for parents. Many materials are free or have a minimal charge. Their Fact Sheet on Traumatic Brain Injury is an excellent place to start. Go to www.nichcy.org to find publications for parents and identify resources in your state, or call 1-800-695-0285.

By Marilyn Lash, M.S.W.

conferences 2010 OCTOBER 6-8 – Joint Meeting of the National Association of State Head Injury Administrators (NASHIA) and the North American Brain Injury Society (NABIS), Minneapolis, MN. For more information, visit nabis.org 7-9 – 23rd Annual Conference on Legal Issues in Brain Injury, Minneapolis, MN. For more information, visit nabis.org 10-12 – Integrative Course on Spasticity Management, Organized by Erasmus University Rotterdam, the Netherlands, Bodrum, Turkey, For more information visit vitalmedbodrum.com 13-16 – 7th World Stroke Congress, Seoul, Korea. For more information, visit www.kenes.com/ stroke2010 13-16 – Annual Meeting of the National Academy of Neuropsychology, The Westin Bayshore, Vancouver, BC. For more information, visit: nanonline.org 20-23 – ACRM-ASNR Joint Educational Conference, Progress in Rehabilitation Research, October 20-23, Montreal, Quebec. For more information, visit acrm.org/annual_conference

Holding Standards High.

NOVEMBER 4-7 – 71st Annual Assembly of the AAPM&R, Seattle, Washington. For more information, visit: www.aapmr.org.

17-19 – 21st Pacific Coast Brain Injury Conference, November 17-19, Vancouver, BC. For more information, visit pcbic.org.

2011 FEBRUARY 18-20 – 21st Annual Meeting- Innovations and Excellence in Skull Base Surgery: The Future is Here, February 18-20, Scottsdale, AZ. For more information, visit nasbs.org/meetings. Abstracts are due October 1, 2010!

2012

For over three decades Beechwood’s interdisciplinary brain injury program has been competitively priced and is nationally recognized for its comprehensive community-integrated approach. As a not-for-profit rehabilitation program, Beechwood has demonstrated that it is possible to provide state-of-the-art treatment at a reasonable cost to the consumer.

Services include: • Physical, occupational, speech, language and cognitive therapies and psychological counseling • Case management • Medical services including on-site nursing, neurological, physiatricand psychiatric treatment • Vocational services from sheltered employment through to community placement • Residential services on a main campus, in community group homes and supported community apartments • Outpatient services

2012 MARCH 22-25 – Ninth World Congress on Brain Injury, Edinburgh, Scotland. For more information, visit internationalbrain.org. This is the official World Congress of IBIA.

A COMMUNITY-INTEGRATED BRAIN INJURY PROGRAM An affiliated service of Woods Services, Inc • Program Locations in PA 1-800-782-3299 • 215-750-4299 • www.BeechwoodRehab.org Beechwood does not discriminate in services or employment on the basis of race, color, religion, sex, national origin, age, marital status, or presence of a non-job related medical condition or handicap.

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non-profit news NORTH AMERICAN BRAIN INJURY SOCIETY

INTERNATIONAL BRAIN INJURY ASSOCIATION

NABIS collaborated with the Alaska Brain Injury Network on a very successful regional conference, the Alaska Brain Injury Conference, which took place in Anchorage, Alaska on July 28-30. Held at the Hotel Captain Cook, over 300 attendees benefitted from presentations from a diverse mix of experts from the local area as well as those from the lower forty-eight. A unique feature of the conference was the attention given to addressing current ABI service and treatment practices in underserved areas and how newly developed approaches can be incorporated within the diverse cultures and regions of Alaska and other states with large geographical areas.

NABIS is working with the National Association of State Head Injury Administrators to put the final touches on our combined annual meeting entitled Brain Injury Partnerships: NASHIA & NABIS in the Twin Cities, which will be held October 5-8, 2010, at the Minneapolis Hilton Hotel. NABIS and NASHIA received 66 abstract submissions for the meeting – a new record! All accepted abstracts will be published in the Journal of Head Trauma Rehabilitation. See the NABIS website for the full program and speaker list!

The joint meeting will be held concurrently with the 23rd Annual Conference on Legal Issues in Brain Injury, a three-day event specifically for attorneys involved in brain injury litigation. This conference will feature an all-star cast of top trial attorneys and medical experts who will present a broad array of practical information covering the latest literature, diagnostic testing methods, rehabilitation, case management, trial techniques and cutting-edge demonstrative evidence.

Visit the NABIS website www.nabis.org for more details!

The International Brain Injury Association is pleased to announce that the Ninth World Congress on Brain Injury will be held March 22-25, 2012, in Edinburgh, Scotland. Edinburgh, the capital of Scotland, is a picturesque historic city, dominated by its famous castle with many fine hotels, restaurants, museums and traditional pubs!

There is easy access to Glasgow, the Highlands and to tourist and sporting opportunities. The Congress will be relevant to professionals who work with people with acquired brain injury and will provide a forum for education, formal and informal discussion and debate. As usual, the scientific program will include talks from internationally renowned experts in the field of brain injury, scientific poster and paper presentations, candlelight sessions with experts, as well as, preand post-conference symposia (including an optional trip to Glasgow to tour some of the key historical sites from the field of brain injury rehabilitation). Up to date research will be presented on a variety of topics ranging from neurobiology to neurorehabilitation and from the theoretical to the very applied. The IBIA awards will be presented, including the Jennett & Plum Award for Clinical Achievement in the Field of Brain Injury Medicine, the Henry Stonnington Award for best review article in Brain Injury, the IBIA Young Investigator Award and the Car of the Year Award. We will have a host of exhibitors to complement more formal aspects of the conference and to encourage collegial networking. A number of social events will be organized that will give opportunities to explore the depth and breadth of Scottish culture and the beautiful scenery of Scotland. Please visit www. internationalbrain.org for more details as they become available.

Brain Injury Association of America

NATIONAL ASSOCIATION OF STATE HEAD INJURY ADMINISTRATORS

In September BIAA will begin celebrating its 30th Anniversary with the release of an updated logo, launch of a new and improved Web site in late October, and publication of a special edition of THE Challenge! in December. You can participate in the celebration by remembering a loved one, honoring someone who’s made a difference in your career or offering congratulations in The Challenge! Visit BIAA’s web site for more information (www.biausa.org). We will soon release the ACBIS application and examination program online. See www.acbis.pro for details. Webinars for professionals, paraprofessionals, administrators and caregivers are scheduled throughout the fall and winter. Visit our Bookstore for more information. The Brain Injury Business Practice College returns to the Historic Menger Hotel in San Antonio, February 22-24, 2011, and once again features presentations and case studies to build business skills and industry contacts. Members of BIAA’s Business and Professional Council (www. braininjurycouncil.org) recently met to strategize next steps on health care reform. BIAA and the Council successfully advocated for the inclusion of rehabilitation in the Affordable Care Act. Continued work in the regulatory phase is necessary to preserve this victory. To that end, BIAA is exploring a partnership with the Brain Trauma Foundation to publish guidelines for rehabilitative treatment and long-term disease management of persons with moderate to severe brain injury.

Dr. Brent Masel is leading this massive effort, which may require your help. Please support BIAA’s work by making a tax-deductible donation, becoming a corporate sponsor or joining the Business & Professional Council today.

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NASHIA is proud to unveil our new, updated logo and website! The look is new, but all the valuable information you have come to expect from NASHIA is still available. Check it out at nashia.org.

In lean economic times, NASHIA’s presence and activities in the Nation’s Capital are even more vital. The NASHIA Public Policy Committee, with Susan Vaughn, Director of Public Policy, and Jean Berube, Governmental Relations, has supported a number of issues and collaborates with numerous disability organizations for crucial program and funding initiatives related to civilians and returning service members with TBI. NASHIA Public Policy Chair Bill Ditto represents NASHIA as a member of the Medicaid Home and Community-Based Medicaid Working Group, promoting collaboration with federal/state Medicaid waiver programs. As a result of this teamwork, NASHIA has written and submitted a white paper, “Characteristics of Medicaid HCBS Services for Individuals with Brain Injury: A Policy Brief and Recommendations” to CMS. Reminder Register Now! The NASHIA and the North American Brain Injury Society (NABIS) joint 2010 conference is being held October 5-8, 2010 at the Hilton in downtown Minneapolis, Minnesota. Join public and private program administrators, service providers, clinicians, researchers, and advocates at this exciting, informative event! More details are available on the NASHIA and NABIS websites.

Remember to check our website for new and exciting changes at www.nashia.org.

book reviews Traumatic Brain Injury in the United States: Emergency Department Visits, Hospitalizations and Deaths 2002-2006 Published by the Centers for Disease Control and Prevention (CDC)

Motor vehicle–traffic injury is the leading cause of TBI-related death.

Motor vehicle–traffic injury rates are highest for adults aged 20 to 24 years.

The CDC estimates 1.7 million traumatic brain injury (TBI) related deaths, hospitalizations, and emergency department visits occur in the U.S. each year, according to recently released report, Traumatic Brain Injury in the United States: Emergency Department Visits, Hospitalizations and Deaths 2002-2006.

There was an increase in TBI-related emergency department visits (14.4%) and hospitalizations (19.5%) from 2002 to 2006 when compared to an earlier CDC study for the years of 1995 to 2001.

Nearly 80% of all known TBI cases are those treated and released from U.S. emergency departments. However, TBI results in an estimated 52,000 deaths each year and TBI is a contributing factor to a third (30.5%) of all injury-related deaths in the United States.

The CDC also found: TBI rates vary by age and by sex. In every age group, TBI rates are higher for males than for females. Children aged 0 to 4 years, older adolescents aged 15 to 19 years, and adults aged 65 years and older are most likely to sustain a TBI. More specifically, males aged 0 to 4 years have the highest rates of TBI-related emergency department visits, hospitalizations, and deaths combined.

TBI injuries have many external causes. Falls are the leading cause of TBI. In particularly, falls result in 523,043 annual TBI-related emergency department visits and 62,334 hospitalizations. TBI rates are highest for children aged 0 to 4 years and for adults aged 75 years and older.

Pediatric Traumatic Brain Injury: New Frontiers in Clinical and Translational Research Edited by Vicki Anderson, PhD and Keith Owen Yeates, PhD

Cambridge University Press, 2010.

ISBN 978-0-521-76332-5 Anderson and Yeates have assembled an impressive group of authors to present what we have learned to date about TBI in childhood and to articulate the challenges we face and how we should go forward in the future. The Editors state that while research in “…pediatric TBI has lagged behind that for adults…this is changing. Research in pediatric TBI now has more solid foundations.”

This excellent textbook features chapters on biomechanics, neurobiology, biomarkers, neuroimaging, and neurobehavioral and neuropsychological outcomes. In addition, several chapters address treatment

There was a 62% increase in fall-related TBI seen in emergency departments among children aged 14 years and younger from 2002 to 2006.

Furthermore, there was an increase in fall-related TBI among adults aged 65 and older, 46% increase in emergency department visits, 34% increase in hospitalizations, and 27% increase in TBI-related deaths from 2002 to 2006.

The data reported in Traumatic Brain Injury in the United States: Emergency Department Visits, Hospitalizations and Deaths 2002-2006 will help to inform TBI education and primary prevention programs, as well as research agendas and policy initiatives. Moreover, these data will help to strengthen the public’s knowledge about the impact of TBI on the lives and health of the American population.

Citation: Faul M, Xu L, Wald MM, Coronado VG. Traumatic Brain Injury in the United States: Emergency Department Visits, Hospitalizations and Deaths 2002–2006. Atlanta (GA): Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2010.

and rehabilitation research and, in particular, various chapters written by Drs. Wade, Catroppa, Anderson, Kolb and Gibb provide a state-of-the-art translation of laboratory research into clinical practice.

As Drs. Andersen and Yeates state, “The time appears ripe for an interdisciplinary and collaborative approach to pediatric TBI that promotes integrative and translational research efforts.”

Their textbook will certainly be recognized as the spotlight for cutting across disciplines and artificial boundaries to better understand and support the needs of children and adolescents with TBI and their families.

BRAIN INJURY PROFESSIONAL

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legislative round-up Susan L. Vaughn, Editor, Legislative Issues

“Hot town, summer in the city, back of my neck getting dirty and gritty. . .”

by The Lovin’ Spoonful During its August recess, the US Representatives were called back to Washington, D.C. to pass legislation to extend the increase in the federal medical assistance percentage (FMAP) for Medicaid in the amount of $16.1 billion through June 30, 2011, and $10 billion in education funding to prevent layoffs of educators. The Senate passed both provisions in H.R. 1586, the Federal Aviation Administration Reauthorization bill during the time the House had adjourned for its recess.

The temporary increase in the Medicaid federal match was enacted through the economic stimulus bill to help States experiencing increased demand for Medicaid coverage and decreased budget revenues as the result of the economy. Unless extended, the increase was set to expire in December, 2010.

In July, several national events and congressional briefings were held commemorating the 20th Anniversary of the Americans with Disabilities Act (ADA) of 1990, which was signed into law July 26, 1990, to prohibit discrimination against individuals with disabilities in private employment, public accommodations, telecommunications, and public transportation and services. There were also numerous celebrations in honor of the 75th Anniversary of Social Security Act and the 45th Anniversary of Medicaid and Medicare.

Meanwhile, federal agencies have been issuing regulations to implement the various provisions of the Affordable Health Care for America Act, H.R. 3590, which was signed into law on March 23, 2010. On July 14, 2010, regulations were issued to require private health plans to cover evidence-based preventive services and immunization with no cost-sharing. In August, HHS, Labor, and the Treasury issued a series of regulations related to the preexisting conditions, annual/lifetime limits, and coverage rescissions. These new protections apply to nearly all individual and group health insurance plans. HHS also pub-

30 BRAIN INJURY PROFESSIONAL

lished rules outlining administrative and eligibility details on an interim high-risk insurance pool for uninsured persons with pre-existing conditions; and on the process of establishing State insurance exchanges.

P.L. 111-148 includes several provisions relating to long-term supports and services including the Community Living Assistance Services and Supports (CLASS Act), the Medicaid Community First Choice Option, and funding to extend Money Follows the Person grants through September 2016. HHS will issue regulations on the CLASS Act no later than October 1, 2012, with a period for public comment.

In August, the Center for Medicaid, CHIP and Survey & Certification sent a letter to State Medicaid directors about several changes relating to new options for offering home and community-based services (HCBS) through the Medicaid State plan. States will have an opportunity to offer services and supports before individuals need institutional care, and also have a mechanism to provide State plan HCBS to individuals with mental health and substance use disorders. These changes will become effective October 1, 2010.

“Essential health benefits” will be defined in future regulations. The law defines essential benefits package to include an array of services including rehabilitative and habilitative services and devices; and mental health and substance abuse services, including behavioral health treatment. In the interim, HHS will take into account good faith efforts to comply with a reasonable interpretation of the term “essential health benefits,” and group health plans must apply this definition consistently.

The Department of Justice’s Civil Rights Division and the HHS Office for Civil Rights issued a new guidance for medical providers to help people with mobility disabilities obtain accessible medical care. Access to Medical Care for Persons with Mobility Disabilities includes an overview of general ADA requirements, commonly asked questions, and illustrated examples of accessible facilities, examination rooms, and medical equipment.

This guidance, notice of grants for improving health care, and proposed health care reform regulations may be found on HHS’ website: www.hhs.gov. No matter how hot the weather may be in the summer, work continues to improve and expand health care options for all Americans.

About the Editor:

Susan L. Vaughn of S.L. Vaughn & Associates, consults with states on service delivery and serves as the Director of Public Policy for the National Association of State Head Injury Administrators. Ms. Vaughn retired from the State of Missouri after nearly 30 years, where she served as the first director of the Missouri Head Injury Advisory Council. She founded NASHIA in 1990, and served as its first president.

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