Traumatic Brain Injury Update: Current Trends in Assessment and Intervention =

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Traumatic Brain Injury Update Current Trends in
Assessment and Intervention
Susan M. Wolf, Ph.D. Executive Director Wattle
and Daub Consulting 10225 East Iris Road Suite
One Mesa, Arizona 85207-3627
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Agenda

• Mr. Brain
• Neurodevelopment
• Epidemiology of injury
• Understanding brain injury
• Areas of impairment
• Neuropsych assessment for disorders
• Interventions in cognitive retraining

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Objectives

• By the end of the training, the participant will
  
• Be able to describe the neurodevelopmental
  implications of childhood traumatic brain injury
  and school functioning
• Be able to identify cognitive-communication
  disorders that can result from brain injury,
  dependent upon the localization of injury.
• Be able to explain their role(s) in relationship
  to neuropsychological assessment and cognitive
  retraining for children who have sustained a
  brain injury.

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Mr. Brain

• Hemispheres
• Lobes
• Brain functions
• Executive Functions

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Mr. BrainBrain Function

• The brain is
• Our personal, private universe.
• What makes us distinctly human.
• Our sensory processor.
• Responsible for reasoning, language, complex
  social relationships, and morality.
• Functioning as an interrelated whole however
  injury may disrupt a portion of its activity that
  occurs in a specific part of the brain.

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Mr. BrainBrain Function

• The brain is
• Most active organ in the body uses the most
  oxygen uses 20 of bodys blood supply brain
  constantly active requiring an uninterrupted flow
  of blood and oxygen blood and oxygen supply to
  the brain takes precedence over all other organs
  of the body when blood supply is interrupted
  neurons and neural networks die
• Brain is approximately 3 lbs in weight 2 of
  total body weight (adult) one trillion neurons
• Baby/childs brain 10 of body mass in a baby
  1/3 size of adult brain during first twelve
  months, brain cells differentiate and begin
  developing neural connections.

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Cognitive Skills/Functions Associated with
Hemispheres of the Brain
Left Hemisphere Logical Words (spelling) Verbal
meaning Vocabulary in language Details
rules Analysis One-by-one selectivity Step-by-step
instructions Sequential ordering Cause and
effect relationships Learned facts Letter-symbol
associations Abstract reasoning Academically-learn
ed information Ideas Serial/ordered
structures Self-verbalizations Selective
attention Consciousness reasoning Scientific
logic
Right Hemisphere Aesthetic Images, pictures,
and colors spatial Music and feelings Gestalt
whole/relational Synthesis, comparisons Simultaneo
us patterning Whole process Whole
units Analogies Creativity new
combinations Visual symbolism Concrete Practical
common sense knowledge Patterns of
things/theory Random-without structure body
language Facial expression, tone of
voice Sustained attention Meditation, spontaneous
ideas, subconscious Spiritual mythical Patterns
of logical associations
Used with Permission Maureen Priestley 2004
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Mr. BrainCerebral Cortex

• Both hemispheres are able to analyze sensory
  data, perform memory functions, learn new
  information, form thoughts, and make decisions.
• But each hemisphere acts upon sensory information
  in a unique manner.

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Mr. Brain

• Left hemisphere
• Concern is with discrete and concrete pieces of
  information.
• Memory is stored in a language format.
• Helps an individual see details and keep
  information organized.
• Helps the individual use language skills (read,
  write, and speak) although each of these skills
  is done in a different lobe of that hemisphere.

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Mr. Brain

• Right hemisphere -
• Memory is stored in auditory, visual, and spatial
  modalities.
• Helps a person see the whole the big
  picture and to put things together (e.g.
  recognize shapes).
• Supports artistic and musical skills and
  abilities.

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Mr. BrainExecutive Function

• Executive Functions are housed in the frontal
  lobes, one of the last areas of the brain to
  fully develop. Refinement (differentiation and
  integration) of the frontal lobes can continue
  into the early 20s.
• Executive Functions are highly dependent upon
  normal neuro-development and the ability to
  acquire higher level cognitive skills.

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Mr. BrainExecutive Function

• Executive Functions represent an individuals
• Capacity for self-control and direction, planning
  and organization, mental flexibility, problem
  solving skills, initiation and motivation.
• Ability to regulate ones thoughts, emotions, and
  behavior.
• Ability to know where one is heading as opposed
  to having no idea of what the consequences will
  be for volitional behavior.

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Mr. BrainExecutive Functions

• Impaired Executive Functions
• may interfere with a persons ability to
• Control emotions.
• Benefit from experience.
• Learn new information.
• Understand social cues.
• Be sensitive to the emotional needs of others.
• To accomplish activities of daily living and to
  live independently.

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Clinical Model of Executive Functions

• Initiation and drive
• Response inhibition
• Task persistence
• Organization
• Generative thinking
• Awareness

• Starting behavior
• Stopping behavior
• Maintaining behavior
• Sequencing and timing behavior
• Creativity, fluency, problem-solving skills
• Self-evaluation and insight

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Brain-behavior Relationships

• Neurodevelopment
• Brain-Behavior Relations
• Model
• New Learning
• Personality

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Neurodevelopment

• Vast difference between the adult brain and the
  childs developing one (size, structure,
  networks).
• From birth to adolescence, the brain undergoes
  dynamic change resulting in increasing
  differentiation and integration.
• Brain development causes maturation in thinking
  ability, behavior, emotional regulation, and
  social capabilities.

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The Developmental Pyramid
16 - 19 Judgment 12 - 16 Integration/ Problem
Solving 6 - 12 New Learning/Attention 3 -
6 Thinking/Emotion/Behavior 0 - 3 Cause/Effect
Relationships
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Key Points in Neurodevelopment

• Injury in childhood can result in an
  underdevelopment of the brain functions of the
  impacted areas.
• Abilities that are just developing or have not
  yet emerged are the most sensitive and more
  likely to be disrupted as a result of brain
  injury.
• These abilities and their associated areas of
  function are likely to be the Achilles Heel for
  a child with a brain injury, even after growing
  up.

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Brain Behavior Relationships

• It is through our brains that we experience
  ourselves, the environment and understand our
  relationships to and with others.
• Our experience of ourselves and our environment
  is dependent on our brains ability to receive,
  process, store, retrieve, and transmit sensory
  information.

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Brain-Behavior Model
OUTPUTS (motor, oral, written)
Concept formation, reasoning, logical analysis
Language skills
Visual-spatial skills
Manipulations in Active Working Memory
Attention, concentration, memory
Inputs Auditory
Inputs Visual
Inputs Kinesthetic
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Brain-Behavior RelationshipsNew Learning

• New learning is ones ability to

• Attend and concentrate on visual, auditory,
  and/or kinesthetic input(s).
• Process information in active, working memory by
  linking new information to visual, auditory,
  and/or kinesthetic memory.
• Encode the new information
• Hold it in memory for a short period of time.
• Integrate it into long-term memory.
• Retrieve the information when necessary
• Timely.
• Accurately.

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Brain Behavior RelationshipsWhat is Personality?

• What does it mean when you say
• someone is reliable?

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Brain-Behavior Relationships

• Brain injury can impact a persons ability to
  store, process, accumulate, and retrieve
  information.
• The extent to which the brain is impaired is what
  assessment and intervention are all about.

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Understanding Brain Injury

• Epidemiology of Injury
• Types of Injury
• Concussion

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• Incidence and Prevalence of TBI

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TBI Data and Research
Traumatic brain injury is now classified as a
public health epidemic in America.

• Centers for Disease Control and Prevention.
  Traumatic Brain Injury in the United States A
  Report to Congress. (January 16, 2001).

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Incidence Prevalence of TBI

• Someone in America will sustain a brain injury
  every fifteen seconds.
• 720 people
• during this
• 3 hour training

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TBI Incidence Prevalence
CDC figures as of 4/02
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The Real Statistics
00
99
98

• Since 1992, on average more than 5,000 Arizonans
  each year sustain a TBI severe enough to cause
  death (20) or hospitalization.

97
96
95
94
93
92
estimate
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Incidence Prevalence of TBI

• Who is at risk?
• Close to 1/3 of those surviving brain injury are
  children and teens.
• Males are 2 times more likely to sustain a TBI
  compared to females.
• Risk of traumatic brain injury is highest in
  adolescents and young adults.
• Second highest risk group is adults older than 75
  yrs.

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Incidence Prevalence of TBI

• How are they injured?
• Motor vehicle crashes account for 50 of all
  traumatic brain injuries.
• Falls are the second leading cause and the most
  prevalent cause among the elderly.
• Violence, particularly from firearms, ranks third.

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Incidence Prevalence of TBI TBI Research
While the behavioral effects of child abuse have
been understood for many years, it is only
recently that we have begun to recognize the
impact of trauma on the physiological development
of a childs brain.
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Incidence Prevalence of TBI TBI Research

• As a result of growing up with violence in their
  homes, many children have neurological deficits
  caused by repeated blows to the head and face
  (most common area hit), and by the chemical
  reaction to prolonged stress.
• Brain alterations caused by shock and trauma of
  witnessing violence, for both women and children,
  is a negative outcome of violence in the home.

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Incidence Prevalence of TBI TBI Research

• These hidden injuries may result in
• Depression Delinquency
• Anxiety PTSD
• Aggression Impulsiveness
• Hyperactivity Mood regulation
• Impulse control Suicidal ideation
• Communication difficulties Substance abuse
• Planning and problem solving difficulties

Brain Injury Source, Winter 1998, Volume 2, Issue
1, pages 12 13
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Understanding Brain Injury
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Understanding Brain InjuryBrain Anatomy
Quick overview (from the outside in)

• Outside - Bony skull
• Inside
• Brain tissue gelatinous substance firm jello
  consistency.
• Brain wrapped in thick covering (dura) that
  protects and segments the brain.
• Within the covering, the brain floats in
  cerebrospinal fluid. It surrounds the brain, and
  under normal circumstances, cushions the brain
  from contact with its hard, spiny shell.

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Understanding Brain InjuryBrain Injury Types
Congenital Brain Injury
Acquired Brain Injury
Traumatic Brain Injury
Non-traumatic Brain Injury
Closed Head Injury
Open Head Injury
Savage, 1991
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Understanding Brain InjuryNon-Traumatic

• Examples of non-traumatic brain injury from
  medical conditions include
• infectious disease (e.g., meningitis,
  encephalitis)
• brain tumor
• cerebral-vascular dysfunction (e.g., stroke,
  cardiac disorders)
• intercranial surgery
• toxic chemical or drug reactions (e.g., lead
  poisoning, carbon monoxide poisoning).
• anoxic/hypoxic episodes.

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Understanding Brain InjuryHypoxia/Anoxia

• Near drowning.
• Suffocation.
• Other injuries (cardio or pulmonary) can reduce
  blood flow and oxygen to the brain.
• Lack of oxygen/blood flow for more than 3 - 4
  minutes causes generalized damage.
• Suicide attempts.

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Understanding Brain InjuryTraumatic
A traumatic brain injury (TBI) is a result of

• Blunt or penetrating trauma to the head such as a
  fall or gunshot wound.
• Coup Contrecoup injury from acceleration -
  deceleration forces such as motor vehicle crashes
  or shaken baby syndrome.

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Understanding Brain Injury

• Primary injury (immediate impact)
• Skull fracture (O)
• Hematomas (C)
• Anoxia/hypoxia (C)
• Contusions (C)
• Axonal shearing (C)

• Secondary injury (reaction to impact)
• Secondary tissue damage/necrosis
• Increased intracranial pressure
• Increased internal temperatures
• Swelling/inflammatory response
• Intracranial infection

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Understanding Brain InjuryCOUP - CONTRECOUP
Injury
LifeArt Williams Wilkins http//www.lifeart.co
m
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Shaken Baby SyndromeViolent shaking or sudden
impact may cause excessive brain movement and
damage bridging cerebral veins.
Shaking Exerts 10x g Force
Impact Exerts 300x g Force
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Understanding Brain InjuryConcussion

• May or may not result in a loss of consciousness.
• Clear structural damage may or may not be present
  on radiographic/imaging studies.
• Can result in dysfunction in the absence of
  structural damage.
• Dysfunction may not be evident until the tasks or
  demands of the environment present the individual
  with challenges for which s/he may not be able to
  compensate.

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Understanding Brain InjuryConcussion Common
Symptoms

• EARLY SYMPTOMS
• Headache
• Confusion
• Dizziness
• Nausea with or without vomiting
• Disorientation to time and place
• Slow to respond or follow instructions
• Being uncoordinated

• LATE SYMPTOMS
• Persistent headache
• Poor attention and concentration
• Memory dysfunction
• Vision disturbance
• Ringing in the ears
• Anxiety and depressed mood
• Irritability
• Intolerance to loud noise

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Understanding Brain InjuryConcussion Related
Issues

• For children and adolescents, whose brain
  development is ongoing, the effects of a
  concussive brain injury may be distinct from
  those seen in adults.
• Repeated concussions, such as sports injuries or
  repeated incidents of abuse can have cumulative
  effects.
• Symptoms related to post-concussive syndrome can
  have significant life-long impairments and
  debilitating effects on those who survive them.

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Understanding Brain InjuryConcussion Common
Symptoms

• Second Impact Syndrome (SIS)
• 2nd concussion while still symptomatic
• Can occur within hours, days or weeks
• May lead to lifelong impairments

• Post-Concussion Syndrome
• Effect of repeated concussions
• Cumulative neurologic and cognitive deficits
• More concussions, more risk

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Understanding Brain Injury

• Mild (70-80), moderate (10-15), and severe
  (5-7) brain injury are the clinical terms used
  to describe the type of brain injury the person
  sustained. (e.g. Glasgow Coma Scale, Rachos Los
  Amigos Scales)
• However, these same descriptors often fail to
  tell us about the functional outcome (long-term
  prognosis) of the injury.

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Areas of Impairment(s)after Injury
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What Does TBI Look Like?

• Functional Impacts
• Personality and Emotional Impacts
• Psychological and Behavioral Impacts

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Functional Impacts of TBI

• Impaired Mobility
• Impaired Body Functions
• Impaired Sensory Experiences
• Impaired Cognitive Functioning
• Impaired Communication

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Functional Impacts of TBI

• Impaired mobility
• Paralysis (partial or full)
• Hemiparesis
• Spasticity, contractures
• Balance and equilibrium
• Gait challenges

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Functional Impacts of TBI

• Impaired body functions
• Swallowing difficulties
• Temperature control
• Changes in other voluntary controls (motor)
• Changes in involuntary controls
• Seizures

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Functional Impacts of TBI

• Impaired sensory experiences
• Vision
• Hearing
• Smell
• Taste
• Touch

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Functional Impacts of TBI

• Impaired cognitive functions
• Decision making and executive functioning
• Attention/Concentration/Distractibility
• Memory (active, short-, long-term)
• Organization
• Judgment and reasoning
• Mental fatigue, lowered pain threshold
• Self-awareness and metacognition

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Functional Impacts of TBI

• Impaired communication
• Understanding language (e.g., aphasia, auditory
  speed of processing concerns, limited verbal
  memory or attention)
• Speaking and producing language (e.g., anomia,
  confabulation, tangential, fragmentation, devoid
  of content)
• Speech patterns (e.g., perseveration, hyperverbal
  speech, cocktail language)
• Poor pragmatics (e.g., poor turn taking, poor
  topic maintenance, reduced sensitivity to partner)

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Functional Impacts of TBI

• Impaired pragmatics is CRITICAL !
• Pragmatics transcend isolated word and
  grammatical structures (discourse in social
  context)
• Pragmatics is an interplay of cognitive and
  affective factors and decreased self-awareness
  also plays a role
• People with TBI often exhibit normal linguistic
  skills but have difficulty adapting communication
  to specific contexts
• Poor pragmatics do not spontaneously improve over
  time (Snow, Douglas, Ponsford (1998))
• Poor pragmatics leads to social isolation and
  because it is critical to community
  reintegration, clinicians have begun to
  prioritize assessment and treatment of deficits.

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Uniqueness of Injury Predictability Challenging

• Very specific areas of impairment may exist
  side-by-side with high-functioning areas
• Example high intelligence but slow visual or
  auditory processing of information
• Example language skills age-appropriate but
  significant working memory impairment
• Location of injury can help determine (to some
  extent) the type(s) and severity of impairment

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Impact Organic-based Personality / Emotional
Changes

• Disinhibition
• Suspiciousness
• Impulsivity
• Lack of awareness of deficit and unrealistic
  appraisal
• Reductions in or lack of the capacity for
  empathy inability to experience emotions
• Childlike emotional reactions or behavior
• Uncontrolled laughing or crying mood swings
  (emotional lability)
• Preoccupation with ones own concerns
  (egocentrism)
• Poor social judgment

• Rage reactions
• Euphoria
• Flat affect
• Agitation
• Reduced or altered sense of humor
• Low frustration tolerance
• Misperception of other peoples facial
  expressions /intentions inability to perceive
  emotions
• Hyper-sexuality or hypo-sexuality
• Catastrophic emotional reactions

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Impact Psychological / Behavior

• Depression
• Anxiety
• Panic
• Shame
• Humiliation
• Grief
• Loss
• Sadness
• Irritability and aggressiveness
• Deep sense of anger over what has happened

• Resentment
• Blame
• Hopelessness and despair
• Helplessness
• Reduced self-esteem
• Withdrawal from social contact
• Increased sense of dependency on others
• Psychologically-based denial or minimization of
  problems
• Defensiveness
• Pre-occupation with the past
• Unrealistic expectations of family, friends,
  co-workers

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Functional Impacts of TBI

• "Left to fend for themselves, the survivors of
  traumatic brain injury, already confused by their
  inability to be the people they were prior to the
  injury, now face the daunting task of
  demonstrating that an injury they do not
  understand and cannot comprehend is producing the
  confusion they cannot communicate."

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Questions
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Assessment

• Psychoeducational Evaluation
• Neuropsychological Evaluation
• Formal and Informal Assessment Discussion

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Psychoeducational Assessment

• Referral Question
• Family History
• Medical/Developmental History
• Educational History
• Primary Language
• Educational/Cultural Limitations
• Classroom or Other Observation
• Assessment Battery (Tests Used)
• Testing Observation and Student Interview

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Psychoeducational Assessment (cont.)

• Discussion of Results
• Summary
• Recommendations Educational/Learning
  Implications
• Referral (i.e., neuropsychologist, clinical
  psychologist, etc.)
• Psychometric Summary (Explanation of Scores)

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Neuropsychological Evaluation

• Background Information
• Reason for referral
• Diagnosis
• Onset of injury, neurophysical insult(s)
• Medical history, pre-injury status
• Developmental, school history
• Psychosocial status
• Previous psychological, neuropsychological, or
  educational evaluation findings

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Neuropsychological Evaluation

• Behavioral Observations
• Alertness and orientation and awareness of
  circumstances
• Memory
• Attention, concentration
• Task persistence, fatigue
• Speed of processing and performance
• Speech-language
• Judgment, reasoning
• Affect, mood
• Test behavior
• Self-monitoring of performance, approach, effort

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Neuropsychological Evaluation

• Findings
• Overall cognitive and intellectual functioning
• Sensory/motor functioning
• Attention and concentration
• Basic, complex, independent
• Memory
• Immediate, over trials, delay, recognition,
  verbal/non-verbal
• Language and Auditory Processing
• Cognitive/verbal subtests (complexity
  input/output)
• Word/speech fluency measures
• Aphasia screening
• Speech sounds / rhythm patterns

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Neuropsychological Evaluation

• Findings
• Constructional abilities / Visual-perceptual
  Motor
• Design copying tasks
• Wechsler performance subtests
• Figure drawing
• Analysis and Synthesis of Complex Information /
  Shifting Set
• Academic Assessment
• Reading
• Spelling
• Math
• Writing
• Personality / Behavioral / Social Assessment
• Adaptive Behavior Assessment (Functional)

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Neuropsychological Evaluation

• Impressions
• Summary of deficits and impairments
• Summary of intact areas of functioning and
  strengths
• Comparison to reported level of pre-injury
  functioning
• Contributing factors to performance
• Impulse control
• Attention / distractibility
• Flexibility
• Fatigue
• Speed
• Awareness of deficits
• Impact on development, learning, social,
  emotional, vocational
• Specific needs

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Neuropsychological Evaluation

• Recommendations
• School programming / Vocational programming
• Therapy needs
• Compensation strategies, adaptations,
  accommodations
• Psychosocial intervention(s)
• Re-evaluation (need for and timing of)

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What critical role can SLPs play in
neuropsychological evaluation?
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Comprehensive Assessment

• Formal (standardized) evaluation tests
• Informal measures such as modified test
  procedures and non-standardized tasks
• Clinical observations
• Simulated situations
• Provides information on strengths and limitations
  as well addressing the unique treatment needs of
  the client

Frank Barrineau (1996) Jrnl of Med Spch-Lng
Path, 4(2) 81-101.
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GROUP DISCUSSION

• Sustained attention
• Divided attention
• Short-term memory
• Long-term (sematic) memory
• Episodic memory
• Prospective memory
• Planning
• Awareness of behavior

• Identify formal (standardized) and informal
  assessments that you have used or can use to
  ascertain impairments in the following areas

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Intervention Approaches after BITime-based
shifts in responsibility

• Environmental modifications
• Behavioral strategies
• Cues, prompts, and checklists
• Teaching task-specific routines
• Pharmacological interventions

• Cognitive-behavioral interventions
• Metacognitive/self-regulatory strategies
• Training in use of compensation strategies
• Practice at task management
• Awareness training and psychotherapy

Primarily EXTERNAL
Primarily INTERNAL
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Some Old Principles of Intervention (Revisited)

• Observe, Observe, Observe
• Gain insight into individuals level of
  readiness (capacity) to participate
• Honor the chasm between pre- and post-morbid self
  (many are very aware of the differences)
• Identify strengths, assets, interests before
  focusing on deficits and impairments
• Have heightened awareness that this population
  presents with more psychological and behavioral
  issues
• Make tasks contextually relevant and meaningful
• Look to modify the environment and task demands
  (your expectations) rather than focusing on
  change in the individual with brain injury

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Sidebar External Compensatory Aids

• Careful needs assessment (with multiple sources
  of input) regarding the clients needs and
  constraints
• Organic factors (relevant physical/cognitive)
• Personal factors (psychosocial/environmental)
• Situational factors (contexts for aid use)
• Options for external aids
• Written planning systems
• Electronic planners
• Computerized systems
• Auditory/visual symbol systems
• Task-specific aids (post-it notes, bulletin
  boards, phone dialers, calculators, refrigerator
  magnets)

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Sidebar External Compensatory Aids

• Adequate preparation for training a client to use
• Patience with clients and caregivers (everyone
  needs reinforcement!)
• Evaluating awareness issues (can procedures
  work?)
• Breaking down the use of an aid into component
  parts
• Anticipating the contexts in which the aid will
  be used
• Training methods
• Effective instructional techniques (academic,
  functional)
• Errorless Instruction (Baddeley Wilson, 1994
  Evans, 2000)
• Prompting (with rapid and gradual fading cues)
• Monitoring clients progress

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Review of Intervention Handouts

• Memory Theory Applied to Intervention
• Functional and Prospective Memory
• Working with Complex Attention
• Managing Dysexecutive Symptoms
• Working to Improve Unawareness
• Research and Contemporary Publications and
  Resources