Core components of project-based intervention after acquired brain injury: Delivering meaningful groups online.

BACKGROUND: Rehabilitation for cognitive-communication impairments following brain injury can be complex given the heterogenous nature of impairments post injury. Project-based intervention has the potential to improve communication skills and create a meaningful real-life context where individuals collaborate to develop a concrete product, which benefits others. While evidence for this intervention is emerging, the COVID-19 pandemic prompted increased use of telehealth interventions to serve people with brain injury. This paper aims to describe a framework for the delivery of project-based intervention via telehealth within community rehabilitation settings; and present several case studies of telehealth groups completed in the United Kingdom and the United States during the COVID-19 pandemic. METHODS: A working group was formed to map the components of project-based intervention onto the rehabilitation treatment specification system (RTSS). This system is a conceptual framework that helps to explain the link between treatment theory and ingredients, allowing a clinician to clearly understand how and why a treatment works. First, a literature search was completed to identify eligible studies on project-based intervention after brain injury. Second, those studies were thematically mapped onto the RTSS to identify important intervention components. Third, the presence of these components was assessed for community brain injury groups delivered via telehealth in the United Kingdom and United States. These groups were further described using a taxonomy of social activities that help to describe the degree of meaningful social engagement. RESULTS: The literature was described with a thematic RTSS summary. Treatment aims focus on skills training and self-efficacy, advocacy and self-empowerment, emotional well-being and quality of life, and collaboration and community belonging. Treatment ingredients involve a range of cognitive and behavioural supports to deliver meaningful activities and contexts to complete a project. Mechanisms of action involve learning by doing and cognitive and affective information processing. All four telehealth groups conducted in the United Kingdom and United States involved at least three treatment aims, >7 targets, and >8 treatment ingredients. All groups reported positive experiences from activities that involve working collaboratively to help others and contribute to society. CONCLUSIONS: Project-based intervention delivered via telehealth has the potential for supporting people with acquired brain injury to improve their communication skills and engage in meaningful, collaborative activity. Application of the RTSS helps clinicians to understand the aims and therapeutic ingredients (or clinician activities) through which a person with brain injury may achieve specific treatment targets during the rehabilitation process. WHAT THIS PAPER ADDS: What is already known on the subject Project-based interventions have the potential to improve cognitive, self-regulatory, behavioural and social communication skills, renegotiate identity and reaffirm sense of self, providing a positive impact on quality of life for persons with acquired brain injuries. Projects serve as a context for meaningful engagement for individuals in the chronic phase of traumatic brain injury recovery, without fulfilling work, family or social responsibilities. However, most published research has involved in-person projects and few projects have been delivered via telehealth. What this paper adds to existing knowledge While past published works have shared core principles of intervention, a variety of projects, durations, dosages and methods have been employed. The current paper provides a framework to support more consistent implementation. By mapping previous project-based interventions to the RTSS, clinicians will have a better understanding of the aims, targets, ingredients and theoretical underpinnings of project-based interventions. In the wake of the COVID-19 pandemic, the shift to telehealth moved interventions to a virtual context. The four case projects in this paper demonstrate that it is possible to conduct project-based interventions via telehealth and provides a clear description to guide clinicians in their delivery. What are the potential or actual clinical implications of this work? This work begins to build the foundation for more rigorous, empirical examination of project-based interventions. By mapping project-based interventions to the RTSS, core aims, targets and ingredients are established that can be objectively examined. This investigation also provides a road map for clinicians who wish to implement this complex intervention.

Navigating the impact of workplace distractions for persons with TBI: a qualitative descriptive study.

Persons with traumatic brain injuries (TBIs) who return to work often struggle with managing environmental distractions due to residual cognitive impairments. Previous literature has established that environmental distractions impact persons with TBI, yet, the extent to which distractions impact workplace performance is unknown. This qualitative descriptive study using phenomenology methods, explored the experiences of seven individuals with TBIs and how they perceived workplace distractions to impact their productivity. Data was collected using semi-structured interviews with seven participants who were diagnosed with mild, moderate, and severe TBIs. Interviews were transcribed and analyzed using thematic analysis. Main findings centered around what environmental distractions impacted work performance, the farther-reaching consequences of distractibility, strong emotional feelings and worry about perceived work performance associated with distractibility, mitigating distractibility through "gaming the attentional system", and utilizing music as a distraction masker to enhance task performance. In light of this study's findings, researchers, and clinicians are encouraged to consider the wider impact of distractions on persons with TBI. The real-life accounts documented in this study will assist researchers and clinicians to account for the impact of environmental distractions in rehabilitation and support employment for persons with TBI.

Usability and Acceptability of a Computer-Based Social Communication Intervention for Persons with Traumatic Brain Injury: A Mixed-Methods Study.

Computer-based interventions for persons with traumatic brain injury (TBI) are a rapidly developing treatment modality. However, the usability and acceptability of such treatments have not been thoroughly studied. We describe the user-experience of a computerized intervention in persons with TBI called the Work-Related Communication (WoRC) program. Two coders used qualitative analysis of semi-structured interviews to complete a thematic content analysis along with a cost-benefit analysis. Ten participants with severe TBI more than 1-year postinjury were interviewed. Seven participants were male, and three were female. Their mean age was 41.6 years (standard deviation: 13.1). All had 4 years of college or less and experienced severe TBIs. A qualitative analysis of the WoRC program usability resulted in the categories of Content (aspects of treatment approach), Interface (aspects of presentation), and Abilities (aspects of the cognitive disorder). WoRC program acceptability categories emerged as Specific (trained strategies can be applied to specific scenarios) and Personal (individual factors related to willingness to implement the trained strategies). The cost-benefit analysis demonstrated a 50.2% reduction in treatment costs, indicating that computer-enhanced interventions are a potentially cost-effective way to increase behavioral outcomes. We discuss these findings as they relate to future development of computer-enhanced programs for persons with TBI.

Tutorial: The Speech-Language Pathologist's Role in Return to Work for Adults With Traumatic Brain Injury.

PURPOSE: Return to work (RTW) is a major life participation metric used for persons with a traumatic brain injury (TBI). Speech-language pathologists (SLPs) have clinical expertise in the cognitive-communication aspects of TBI. This clinical focus article aims to support the clinical practice of SLPs by summarizing key interprofessional vocational rehabilitation (VR) models and illustrating the role of the SLP throughout the RTW process with a case study. METHOD: This clinical focus article was written by the Academy of Neurologic Communication Disorders and Sciences TBI Research Group along with a VR expert. Authors engaged in deliberative, agenda-based discussions beginning with a literature review based on previous systematic studies. Discussions explored relevant VR and SLP practices. RESULTS: This clinical focus article presents key VR models in parallel with SLP assessment and treatment to illustrate best practice patterns in an RTW field with a dearth of SLP-specific literature. We summarize general VR approaches and four evidence-supported VR models for adults with TBI. We highlight how a model of interprofessional assessment can assist with planning and communication of important work-related concerns. We illustrate how the chronological model of work return can assist with developing goals and planning treatment. CONCLUSIONS: SLPs play an important role in identifying, managing, and collaborating with an RTW team following TBI. A working knowledge of VR models can assist with improving the dialogue between SLPs and VR professionals and can inform practice when working with persons with TBI who have work return as a goal.

Computer-based workplace communication training in persons with traumatic brain injury: The work-related communication program.

OBJECTIVE: This proof-of-concept study presents a computer-based social communication training for spoken workplace interactions called Work-Related Communication (WoRC) training. This program implements didactic training, role-play, and immediate feedback using a simulation approach to improve spoken language performance. The unique target of this training is a category of linguistic markers called politeness markers which are essential for cooperative workplace exchanges. METHODS: We recruited eight adults with chronic traumatic brain injury. All participants demonstrated reduced politeness marker use in language sampling before treatment. This study had a quasi-experimental treatment design. We measured the rate of politeness marker use (politeness markers per minute) using the Voicemail Elicitation Task and novel role-play tasks, and the La Trobe Communication Questionnaire as outcome (dependent) variables. RESULTS: After training, participants demonstrated an increase in trained and untrained politeness marker use that was significant for the novel role-play tasks. The La Trobe Communication Questionnaire found that familiar conversation partners reported a significant increase in social communication skills. CONCLUSION: The WoRC program has implications for introducing a sociolinguistic foundation for social communication training in general and specifically for vocational placement.

Social Communication Following Adult Traumatic Brain Injury: A Scoping Review of Theoretical Models.

Purpose Social communication is the set of abilities that allows individuals to achieve relevant social goals across contexts. Speech-language pathology evaluation and treatment of traumatic brain injury (TBI)-related social communication problems should be informed by evidence-supported theories of social communication. The primary purpose of this article is to summarize the results of a scoping review of theoretical models that speech-language pathologists may apply to the evaluation and treatment of social communication problems of adults with TBI. Method A scoping review was conducted of PubMed, PsycINFO, and Embase for sources published in English between 1989 and 2020 that described human social communication and participation. Resulting sources were systematically examined for social communication models. Results Nine theoretical models were identified that speech-language pathologists may apply to their assessment and treatment of social communication abilities of adults with TBI. Identified models were categorized thematically into one of three classes: cognitive models, social competence models, and pragmatic models. Using a framework developed for the purposes of this article, each identified model was evaluated, and one exemplar model in each class is described in depth. Conclusions Social communication problems in adults post-TBI are common. The existence of multiple models empowers speech-language pathologists to select individual-focused assessment and treatment approaches to maximize intervention outcomes.

The Voicemail Elicitation Task: Functional Workplace Language Assessment for Persons With Traumatic Brain Injury.

Purpose Politeness markers (PMs) are words that enhance cooperativity in dialogue and are an essential component of professional/work communication. Persons with moderate/severe traumatic brain injury (TBI) underuse PMs in connected speech and have employment stability issues. The voicemail elicitation task (VET) is a standardized computerized language sampling procedure measuring PM rate in role-play tasks. Our purpose is to provide preliminary data establishing the potential of a screening assessment tool for professional/work communication. Method We measured VET performance using spoken PMs per minute (PMpM). We present data from 63 persons. Forty-three participants with TBI (22-65 years old, ≥ 1-year postinjury) worked in midlevel jobs before their injury and attempted work return after injury at the same job level. Twenty participants with TBI did not maintain work > 1 year (unstably employed), and 23 did maintain work for ≥ 1 year (stably employed). Twenty controls without history of neurological impairment working at the same job level also completed the VET protocol. We analyzed the data using between-group comparison with 1-way analysis of variance and post hoc analysis. We used receiver operating characteristic curve analysis to calculate sensitivity and specificity, as well as an optimal cutoff value for a screening measure. Results Group differences, F(2, 60) = 19.59, p = .0001, η2 = .376, were identified between unstably employed persons with TBI performing with lower PMpM scores than the stably employed TBI group and the control group. Receiver operating characteristic curve analysis indicated a cutoff score of 11.55 PMpM. There was acceptable specificity (0.700, 95% CI [0.499, 0.901]) and sensitivity (0.696, 95% CI [0.508, 0.883]) for a screening tool indicating further assessment of social communication. Conclusion The VET holds promise as a clinical screening tool to identify persons at risk for social communication-related job instability after TBI and the need for a more comprehensive social communication assessment.

Social communication following traumatic brain injury part I: State-of-the-art review of assessment tools.

PURPOSE: The primary aim of this paper was to identify and describe current social communication assessment tools for adults with traumatic brain injury. METHOD: We conducted a state-of-the-art review to identify and categorise the range of social communication assessment tools found in the assessment and treatment literature that revealed 42 measures that were coded according to characteristics related to assessment types, psychometrics, and implementation. RESULT: Of the 42 assessments, 64% evaluated social cognition and the remaining 36% evaluated communication. Coding of implementation categories revealed that only 18/42 (43%) measures were ecologically grounded and 23/42 (55%) were available to clinicians by purchase or in the public domain. Only three measures incorporated questions or an assessment of the examinee's priorities or concerns. CONCLUSION: A number of factors limit current social communication assessment. The lack of tools that objectively and reliably evaluate communication or social cognition in ecologically valid ways remains problematic. Of particular concern is the lack of prioritisation of the individual's communication values and needs. Recommendations include a call to focus research on the development of more contextual, standardised assessments, consider availability and feasibility when tools are being developed, and evaluate assessment processes as well as discrete tools.

Social communication following traumatic brain injury part 2: Identifying effective treatment ingredients.

PURPOSE: Social communication deficits are a severely debilitating aspect of traumatic brain injury (TBI), and there is strong clinical and research interest in how social communication interventions work for this population. Informed by a companion paper targeting assessment of social communication impairments post-TBI, this paper reviews relevant treatment theories and provides an inventory of social communication treatment components. METHOD: We completed a mapping review examining 17 articles from recent literature reviews and 4 updated articles from a literature search to identify treatment targets and ingredients using the Rehabilitation Treatment Specification System (RTSS). RESULT: Social communication interventions are primarily based on behavioural and cognitive treatment theories. Common social communication treatment targets include changing skilled behaviours and cognitive or affective representations. We offer a menu of therapeutic ingredients and treatment considerations which represent the current state of social communication interventions. CONCLUSION: By reviewing the social communication intervention literature through a theoretical lens, we identify which treatment targets are missing, which targets are being addressed, and which therapeutic ingredients (i.e. clinician activities) are recommended. A hypothetical case study is provided as a supplement to demonstrate how speech-language pathologists may integrate treatment theory, ingredients, and targets into clinical practice.

Response to text-based social cues in the formation of causal attributions in adults with traumatic brain injury.

BACKGROUND: Adults with traumatic brain injury (TBI) may have deficits recognizing spoken social cues, with major negative social consequences. We do not know if these deficits extend to written social cues. Written cues, such as letterhead, provide information we use to make critical inferences about an author's perspective, and interpret subsequent text considering that perspective, and thus are critical for social communication. This study examined response to written social cues in adults with and without TBI. METHODS AND PROCEDURES: We asked adults with TBI (n = 38) and uninjured adults (n = 20) to read an article describing actions of a mass murderer and give reasons for the those actions. Materials were presented on letterhead from either a social or a personality institute, to bias responses to either situational or dispositional factors. We hypothesized persons with TBI would be less likely to show bias consistent with the letterhead. MAIN OUTCOMES AND RESULTS: Significantly more comparison-group responses (72%) than TBI-group responses (52%) were biased (p = 0.01) to match the institute in the letterhead. CONCLUSIONS: Results indicated reduced sensitivity to written social cues in adults with TBI. Our findings add to evidence of impaired social cue response after TBI, and extend this to written text.

Characterizing common workplace communication skills for disorders associated with traumatic brain injury: A qualitative study.

BACKGROUND: Interpersonal skill deficits are the primary reason for workplace separation after traumatic brain injury (TBI). Communication is integral to interpersonal skills, but workplace communication demands are inadequately described in the rehabilitation literature. OBJECTIVE: This study describes inter-stakeholder examples of workplace communication behaviors for a level of employment to which people with TBI commonly attempt to return. METHODS: Setting: Mid-level workplaces.Design: Semi-structured interviews were audio recorded, transcribed verbatim, then analyzed using thematic content analysis. Findings were linked to common communication deficits in persons with TBI.Participants: A volunteer sample of twenty healthy individuals employed in the mid-level workplaces, ten employees and ten supervisors.Main Outcome Measure(s): Taxonomy of communication skill deficits common in persons with TBI and associated with mid-level workplaces. RESULTS: Interviews revealed seven communication-related skills associated with mid-level employment: 1) spoken language processing; 2) verbal memory; 3) reading and writing; 4) verbal reasoning; 5) expressive pragmatics; 6) multi-tasking; and 7) social cognition. CONCLUSION: Workers and supervisors from an assortment of mid-level jobs with differing job contents all identified similarly common and important cross-occupational communication-related skills. Findings provide a preliminary guide to assess and treat communication skills for patients who have work re-entry as a goal.

Job stability in skilled work and communication ability after moderate-severe traumatic brain injury.

PURPOSE: Communication deficits may play a critical role in maintaining employment after traumatic brain injury (TBI), but links between specific communication deficits and employment outcomes have not been determined. This study identified communication measures that distinguished stably employed versus unstably employed adults with TBI. METHODS: Participants were 31 adults with moderate-severe TBI who were employed full-time for at least 12 consecutive months before injury in skilled jobs and had attempted return to skilled jobs after injury. Sixteen had achieved stable employment (SE) post-injury, defined as full-time employment for ≥12 consecutive months; and 15 had unstable employment (UE). Participants completed a battery of communication tests identified in a prior qualitative study of communication skills required for skilled work. RESULTS: Measures of spoken language comprehension, verbal reasoning, social inference, reading and politeness in spoken discourse significantly discriminated between SE and UE groups. Two nested models were completed and compared. The first model excluded discourse data because of missing data for two UE and one SE participant. This model revealed that measures of verbal reasoning speed (ß = -0.18, p = 0.05) and social inference (ß = 0.19, p = 0.05) were predictive independent of the overall model. The second model included discourse politeness data and was a better overall predictor of group membership (Likelihood ratio test, Model 1: 3.824, Model 2: 2.865). CONCLUSION: Communication measures were positively associated with SE in skilled jobs after TBI. Clinicians should include assessment of communication for adults attempting return to work after TBI, paying specific attention to social inference and speed of verbal reasoning skills. IMPLICATIONS FOR REHABILITATION: Traumatic brain injury (TBI) often results in communication impairments associated with the cognitive skills underlying interpersonal skills. Communication impairment after TBI has been anecdotally associated with job instability. This research associate communication functioning with work stability after TBI in skilled jobs. These findings indicate that communication impairment should be assessed in persons with TBI returning to skilled employment after injury.

Supporting the literacy skills of adolescents with traumatic brain injury.

Traumatic brain injury (TBI) can affect developmental trajectories as well as language, attention, memory, executive functions, and other cognitive skills related to literacy. Literacy demands change through adolescence and into young adulthood, with academic literacy demands increasing and vocational literacy demands being introduced. Speech-language pathology services must evolve with the literacy needs of each client. This article discusses assessment and treatment approaches designed for adolescents with TBI and recommendations for adapting literacy interventions from the learning disabilities literature. Through proper assessment and intervention, speech-language pathologists can have a meaningful impact on the academic and vocational literacy needs of adolescents with TBI.

Social cognition in adolescent girls with fragile x syndrome.

This study aimed to characterize social cognition, executive functions (EFs), and everyday social functioning in adolescent girls with fragile X syndrome, and identify relationships among these variables. Participants were 20 girls with FXS and 20 age-matched typically developing peers. Results showed significant between-groups differences in social cognition, accounted for by differences in IQ and language. Within the FXS group, IQ and language were related to social cognition; parent-reported social functioning was related to language and EFs; and self-reported social functioning was generally good and not related to cognitive or social cognition variables. Results suggest that intervention might focus on managing language and cognitive contributions to social functioning, rather than social cognition, and underscore the importance of considering parent and adolescent perspectives.

Adolescent Brain and Cognitive Developments: Implications for Clinical Assessment in Traumatic Brain Injury.

Adolescence is a time of significant physical, social, and emotional developments, accompanied by changes in cognitive and language skills. Underlying these are significant developments in brain structures and functions including changes in cortical and subcortical gray matter and white matter tracts. Among the brain regions that develop during adolescence are areas that are commonly damaged as a result of a traumatic brain injury (TBI). This paper summarizes major brain changes during adolescence and evidence linking maturation of these cognitive and language functions to brain development, placing consideration of both areas of development in the context of rehabilitation for adolescents with TBI.