Errorless learning of functional life skills in an individual with three aetiologies of severe memory and executive function impairment.

Errorless learning (EL) procedures have been shown to be effective in teaching new information and new procedures to individuals with severe memory impairment. The published studies have been based on comparatively short-term interventions delivered to individuals with relatively circumscribed impairments. In this single case study, we explore the usefulness of errorless learning procedures used for seven years with an adult with profound and complicated memory and executive function impairments associated with three distinct aetiologies. In primary functional areas targeted by the intervention, outcome was documented by behavioural descriptions and a frequency rating scale. Caregiver burden was documented with qualitative descriptors. A financial cost-benefit analysis is also provided. In the absence of change in underlying neuropsychological impairments, DI's everyday functioning in critical areas improved substantially, with corresponding reduction in supports and improved quality of life. Caregiver burden was reduced to acceptable levels and cost-benefit analysis demonstrates substantial ongoing cost savings.

Apprenticeship in self-regulation: Supports and interventions for individuals with self-regulatory impairments.

In many settings, including schools and other community settings, an increasing number of individuals are identified with relatively weak self-regulation. This article describes an apprenticeship approach to serving children, adolescents and adults with self-regulation problems. The approach highlights antecedent supports for successful participation in meaningful activities and interactive procedures designed to equip the individual with the tools needed to regulate behaviour and emotions in a strategic and successful manner. This approach is consistent with Vygotskyan developmental and pedagogical theories as well as the theory and practice of Positive Behaviour Interventions and Supports in behavioural psychology. The article ends with the presentation of a mosaic of evidence supportive of this approach.

Metaphoric identity mapping: facilitating goal setting and engagement in rehabilitation after traumatic brain injury.

Difficulty re-establishing an organised and compelling sense of personal identity has increasingly been identified as a critical theme in outcome studies of individuals with severe traumatic brain injury (TBI) and a serious obstacle to active engagement in rehabilitation. There exists little empirical support for approaches to identity reconstruction that address common impairments associated with TBI. Similarly, there is as yet little empirical support for theoretically sound approaches to promoting engagement in goal setting for this population. This article has two purposes. First, theory and procedures associated with metaphoric identity mapping are discussed in relation to goal setting in TBI rehabilitation. Second, the results of a qualitative pilot study are presented. The study explored metaphoric identity mapping as a facilitator of personally meaningful goal setting with five individuals with significant disability many years after their injury. Drawing on principles of grounded theory, the investigators extracted data from semi-structured interviews with clients and clinicians, from focus groups with the clinicians, and from observation of client-clinician interaction. Analysis of the data yielded five general themes concerning the use of this approach: All clients and clinicians found identity mapping to be an acceptable process and also useful for deriving meaningful rehabilitation goals. Both clients and clinicians saw client-centred goals as important. Cognitive impairments posed obstacles to this goal-setting intervention and mandated creative compensations. And finally, identity-related goal setting appeared to require a "mind shift" for some clinicians and demanded clinical skills not uniformly distributed among rehabilitation professionals.

Validated instructional practices: application to students with traumatic brain injury.

OBJECTIVE: There is a lack of empirical evidence of effectiveness for instructional interventions for children with traumatic brain injury (TBI). This article addresses this issue by providing an in-depth examination of instructional methodologies validated with other populations of students (with and without disability) and their potential for teaching children with TBI. DESIGN: Literature review. CONCLUSIONS: Two instructional approaches--Direct Instruction and cognitive strategy intervention--have significant evidence supporting their use with many populations of children, with and without disabilities, and address many of the common needs and learning characteristics of students with TBI, thus showing particular promise for these students. Given the efficacy of these 2 approaches with students with similar learning and behavioral characteristics, the authors recommend establishing and funding a systematic research agenda to test their effectiveness with students with TBI.

Intervention for executive functions after traumatic brain injury: a systematic review, meta-analysis and clinical recommendations.

A systematic review of studies that focused on the executive functions of problem solving, planning, organising and multitasking by adults with traumatic brain injury (TBI) was performed through 2004. Qualitative and quantitative methods were used to evaluate the 15 studies that met inclusion criteria. Demographic variables, design and intervention features, and impairment and activity/participation outcomes (ICF) (World Health Organization, 2001) were documented. Five randomised control treatment (RCT) studies used step-by-step, metacognitive strategy instruction (MSI) and outcomes were evaluated in a meta-analysis. Effect sizes (ESs) from immediate impairment outcomes after MSI and "control" intervention were similar to each other, and both were significantly larger than chance. ESs from immediate activity/participation outcomes after MSI were significantly larger than the ESs from control intervention, and both were significantly larger than chance. These results, along with positive outcomes from the other group, single-subject design and single case studies, provided sufficient evidence to make the clinical recommendation that MSI should be used with young to middle-aged adults with TBI, when improvement in everyday, functional problems is the goal (Level A) (American Academy of Neurology, 2004). Although maintenance effects were generally positive, there was insufficient data quantitatively to evaluate this. Furthermore, there was insufficient evidence to make clinical recommendations for children or older adults. Intervention that trained verbal reasoning and multi-tasking was promising, although the evidence is insufficient to make clinical recommendations at this time. Additional research needs were highlighted.

Evidence-based practice guidelines for instructing individuals with neurogenic memory impairments: what have we learned in the past 20 years?

This article examines the instructional research literature pertinent to teaching procedures or information to individuals with acquired memory impairments due to brain injury or related conditions. The purpose is to evaluate the available evidence in order to generate practice guidelines for clinicians working in the field of cognitive rehabilitation. A systematic review of the instructional literature from 1986 to 2006 revealed 51 studies meeting search criteria. Studies were analysed and coded within the following four key domains: Population Sample, Intervention, Study Design, and Treatment Outcomes. Coding included 17 characteristics of the population sample; seven intervention parameters; five study design features; and five treatment outcome parameters. Interventions that were evaluated included systematic instructional techniques such as method of vanishing cues and errorless learning. The majority of the studies reported positive outcomes in favour of systematic instruction. However, issues related to the design and execution of effective instruction lack clarity and require further study. The interaction between the target learning objective and the individual learner profile is not well understood. The evidence review concludes with clinical recommendations based on the instructional literature and a call to clinicians to incorporate these methods into their practice to maximise patient outcomes.

Behavioural interventions for children and adults with behaviour disorders after TBI: a systematic review of the evidence.

OBJECTIVE: To systematically review the evidence for the effectiveness of behavioural interventions for children and adults with behaviour disorders after TBI. DESIGN: Using a variety of search procedures, 65 studies were identified. This literature was reviewed using a set of questions about participants, interventions, outcomes and research methods. PARTICIPANTS: The 65 studies included 172 experimental participants, including children and adults. INTERVENTIONS: A number of specific intervention procedures were used, falling into three general categories: traditional contingency management, positive behaviour interventions and supports and combined. RESULTS: All of the studies reported improvements in behavioural functioning. CONCLUSIONS: Behavioural intervention, not otherwise specified, can be considered a treatment guideline for children and adults with behaviour disorders after TBI. Both traditional contingency management procedures and positive behaviour support procedures can be said to be evidence-based treatment options. However, a variety of methodological concerns block stronger conclusions.

Pediatric brain injury: social, behavioral, and communication disability.

Communication-related disability is common after childhood traumatic brain injury. In most cases, the problems are secondary to executive function, cognitive, or behavioral impairments. Many of the problems persist and have been documented in children with mild and severe injuries. Persistent disability tends to be more severe in children injured at younger ages and often grows in severity over the developmental years. After reviewing the outcome literature, this article presents current approaches to behavioral and social-communication disability.

Context-sensitive cognitive-behavioural supports for young children with TBI: a replication study.

OBJECTIVE: To replicate an investigation of the effects of a multi-component cognitive-behavioural intervention on the challenging behaviour of two young children with growing behavioural concerns after TBI. EXPERIMENTAL DESIGN: Single-subject reversal designs used to document the effects of the combined behavioural, cognitive and executive function intervention on the following dependent variables: frequency and intensity of aggressive behaviours, amount of work accomplished. PARTICIPANTS: Two young children with escalating behaviour problems after TBI. INTERVENTION: Integrated components of positive behaviour supports, cognitive supports (e.g. graphic organizers) and an executive function routine (goal-plan-do-review). RESULTS: Reduced frequency and intensity of challenging behaviours; increased quantity of work completed. CONCLUSIONS: Positive replication of previous single-subject experiments demonstrating the potential for successfully treating behaviour disorders in young children with TBI using a support-oriented intervention that combines behavioural, cognitive and executive function components.

The use of standardized tests for individuals with cognitive-communication disorders.

The assessment of individuals with cognitive-communication disorders after traumatic brain injury can present a major challenge to speech-language pathologists. For this reason, the Academy of Neurologic Communication Disorders and Sciences Practice Guidelines Group dedicated a specific writing committee to this topic. This article summarizes the writing committee's efforts related to the use of standardized, norm-referenced tests. The article begins with the key questions speech-language pathologists might ask in choosing a standardized test. We then provide a summary of the results of the writing committee's data-gathering activities and a brief description of the tests that appeared to meet most established criteria for validity and reliability for use with this clinical population. The article concludes with the identification of areas in which instruments and additional normative data are needed.

Nonstandardized assessment approaches for individuals with traumatic brain injuries.

Nonstandardized assessment procedures serve a variety of purposes, including determining competencies in domains for which there are no standardized tests, describing performance in the context of real-world settings and activities, and exploring the effects of systematic changes in communication and cognitive demands and partner supports. This article reviews evidence on the use of nonstandardized procedures for the assessment of individuals with traumatic brain injury and offers recommendations for the use of the procedures that are supported by the available evidence.

Behavioral and social interventions for individuals with traumatic brain injury: a summary of the research with clinical implications.

Specialists in communication disorders who work with individuals who have traumatic brain injury (TBI) often focus their rehabilitative efforts on the cognitive, social, and behavioral dimensions of disability. These domains of functioning are included in the scope of practice of the American Speech-Language and Hearing Association because of their close associations with communication effectiveness. This article summarizes relevant research findings and clinical perspectives in the areas of intervention for disorders of behavioral self-regulation and social-interactive competence after TBI. This clinical summary is associated with a systematic evidence review sponsored by the TBI Practice Guidelines Group of the Academy of Neurologic Communication Disorders and Sciences (ANCDS).

Rehabilitation and ongoing support after pediatric TBI: twenty years of progress.

This article summarizes major developments of the past 20 years in both acute and chronic management of children with traumatic brain injury. The article begins with brief summaries of developments in acute and rehabilitative medical management and physical rehabilitation. Because long-term cognitive, behavioral, academic, and family issues tend to be dominant after pediatric TBI, more attention is given to these topics. The article ends with a list of general themes that have been identified as critical in providing effective long-term services and supports to children with TBI and their families.

Context-sensitive behavioral supports for young children with TBI: short-term effects and long-term outcome.

OBJECTIVE: To investigate the effects of a multicomponent cognitive-behavioral intervention on the challenging behavior of two young children with growing behavioral concerns after traumatic brain injury. DESIGN: Single-subject reversal designs were used to document the effects of the intervention on the specific dependent variables. In addition, qualitative data were collected to determine the children's long-term outcome and staff evaluations of the intervention. PARTICIPANTS: Both children were normally developing before injury at age 5 years. Both experienced increasing behavior problems as expectations in school escalated. MAIN OUTCOME MEASURES: Quantitative data included frequency and intensity of aggression and amount of work completed. Qualitative data included children's general engagement in school work and peer interaction and staff evaluations of the intervention. INTERVENTION: The intervention included components of positive behavior supports, cognitive supports, and an executive function routine. RESULTS: The targeted challenging behaviors were reduced to near zero with decreased intensity. Long-term outcome was positive. CONCLUSIONS: These results illustrate the potential for successfully treating behavior disorders in young children with traumatic brain injury using a support-oriented intervention that combines behavioral and cognitive components.

Positive supports for people who experience behavioral and cognitive disability after brain injury: a review.

BACKGROUND: Behavioral and cognitive problems are among the most common and troubling consequences of traumatic brain injury. Furthermore, behavioral and cognitive challenges typically interact in complex ways, necessitating an integrated approach to intervention and support. OBJECTIVES: This article reviews literature on behavioral outcome in children and adults with traumatic brain injury, traditional approaches to behavioral intervention and cognitive rehabilitation, and the history, principles, and assessment and treatment procedures associated with context-sensitive, support-oriented approaches to behavioral and cognitive intervention. We propose a clinical framework that integrates cognitive and behavioral intervention themes.

Executive functions, self-regulation, and learned optimism in paediatric rehabilitation: a review and implications for intervention.

Success for children and adults alike in educational, vocational, and social pursuits depends heavily on effective self-regulation of cognitive and social behaviour. Our goal in this article has been to summarize recent literature on executive self-regulatory functions, their importance, their development during childhood, the types of disability associated with EF impairment, and intervention approaches that have been shown to be useful for related disability groups. We also examined the literature on learned helplessness and learned optimism for clues to a comprehensive approach to helping children with EF impairment, in particular those with acquired brain injury. The central rehabilitation-relevant themes that we have derived from these reviews are: (a). although brain injury can directly impair executive self-regulation, aspects of the environment and the presence or absence of support behaviours of others can reduce or amplify the neurologic impairment; (b). interventions need to be context sensitive; (c). everyday routines of instruction and parent-child interaction are the ideal context within which to provide EF facilitation; and (d). a primary role for rehabilitation specialists is to help everyday people effectively organize and modulate their support for and everyday interactions with children with disability. In an ideal world, competent and optimistic rehabilitation professionals work collaboratively with children and their parents, teachers and others to ensure an optimistic vision of the future that includes an increasingly autonomous child with the executive self-regulatory skill needed to succeed in adult life.

Perspectives on rehabilitation of individuals with cognitive impairment after brain injury: rationale for reconsideration of theoretical paradigms.

BACKGROUND: The frequency of cognitive impairment associated with traumatic brain injury (TBI) has led to the widespread use of cognitive rehabilitation as a discrete rehabilitative service. This service has become controversial in part because of disagreements regarding its theoretical base and implementation procedures, and in part because of insufficient experimental support. OBJECTIVE: We outline two paradigms for cognitive rehabilitation that are interestingly different, both theoretically and procedurally. These paradigms are defined in relation to the goals of intervention, orientation to assessment, modalities of treatment, organization of treatment, and logistics of service delivery (setting, content, and provider). A rationale for each paradigm is described. CONCLUSION: We conclude with a call for (a) additional research into the effectiveness of interventions for individuals with cognitive impairment after TBI and (b) clinicians' thoughtful reflection on the foundations of their service.