HELPING ADULTS WITH TBI & CO-OCCURRING DISABILITIES SUCCEED IN READING

Melissa Capo, M.S., CCC/SLP ~ NYS/DOH Neurobehavioral Resource ProjectSouthern Tier Independence Center ~ Latham, NY

PRINCIPLES GUIDING THE INTERVENTIONS

1. The person is the core of all intervention and support efforts

2. Interventions and supports are organized around personally meaningful activities

3. Contextual supports are critical to success

4. Reduction of supports is part of the plan

5. Positive everyday routines are the context for pursuit of meaningful goals

6. Feedback is context-sensitive and meaningful

7. Components of life must be integrated

8. Assessment is ongoing and context-sensitive

9. Behavioral concerns are addressed via positive behavior supports

10.The ultimate goal for participants is effective self-regulation within a meaningful life

Ylvisaker, M. (2006)

ASSESSMENT

American Speech-Language Hearing Association November 18, 2010~ Philadelphia, PAAmerican Speech-Language Hearing Association November 18, 2010~ Philadelphia, PA

SPECIFIC INTERVENTION SUPPORTSSummary of Complex Needs and Associated Supports

INTRODUCTIONIndividuals with TBI and co-occurring disabilities represent a challenge to speech and language pathologists in various rehabilitation settings. This poster illustrates an intervention approach used to help a group of adults with TBI increase their literacy skills in order to achieve meaningful engagement and reduce challenging behavior. NEUROBEHAVIORAL RESOURCE PROJECT (NRP)To meet the chronic support needs of this population, the NYS TBI Medicaid Waiver Program provides clinical, medical and independent living supports to individuals with TBI, residing in the community, who would otherwise require nursing home level care. The NRP is a grant-funded support to the Waiver program, supporting individuals who represent significant challenges to service providers and are likely diagnosed with a pre- or post-injury co-occurring disability (i.e., substance abuse and /or mental health disorder).

PERSON-CENTERED PLANNING: A Change in CultureNRP staff were directed to provide direct and ongoing support to a community-based program that was struggling to successfully serve this complex population. Like many rehabilitation programs, this provider focused on clinician- directed interventions which led to less than positive outcomes. NRP staff recommended a shift in focus from traditional clinician-directed interventions to participant-directed, person-developed, person-centered services.

EXAMPLES: Individual Projects

•Group Facilitator

•50 Cent Words dictionary

•Political Debate

•Novel-related research

EXAMPLES: Group Projects

•Current events discussions

•Novel-related, topic-specific research

•Novel-themed lunch

•Identification of effective

comprehension strategies

•Identification of effective decoding

strategies

SELECTED REFERENCESChapey, R., Duchan, J.F., Elman, R.J., Garcia, L.J.,

Kagan, A., Lyon, J., & Simmons Mackie, N. Life participation approach to aphasia: A statement of values for the future. http://www.asha.org/public/speech/disorders/LPAA.htm

Feeney, T.J. & Capo, M. (2010). Making meaning: The use of project-based supports for individuals with brain injury. Journal of Behavioral and Neuroscience Research, 8(1), 70-80.

Ylvisaker, M., Feeney, T. & Capo, M. (2007). Long-term community supports for individuals with co-occurring disabilities after traumatic brain injury: Cost effectiveness and project-based intervention. Brain Impairment, (8)2, 276-292.

Ylvisaker, M,. & Feeney, T. (2009). Apprenticeship in self-regulation: Supports and Interventions for individuals with self-regulatory impairments. Developmental Neurorehabilitation, (12)5, 370-379.

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WHO CRITERIA:

IMPAIRMENT, ACTIVITY & PARTICIPATION LIMITATIONSDESCRIPTION OF SUPPORTS

COMMUNICATION:

Aphasia

Use of AAC

Dysarthria

Non-English Speaking

COGNITIVE:

Memory

Attention

Organization

Language Comprehension

General Reading Difficulty

Pre-injury learning disability

EXECUTIVE FUNCTION

Goal setting

Identification of obstacles

Planning/problem solving

Initiation/impulse control

Flexibility

Self-monitoring/Self-evaluation

BEHAVIORALMotivation

Impulsiveness

Anger Management

Substance Abuse

Mental Health (anxiety, depression, PTSD)

Lack of engagement in meaningful activities

•Implementation of Goal, Obstacle, Plan, Do, Review

structure for all activities

•Use of executive function scripts

•Supported transitional routines, individualized for

some participants

Weekly planning of future group activities

Weekly Group review of successes and needs

•Positive Behavior Intervention Supports

•Participant-centered and participant driven group

•Liberal use of supports to ensure success

• Negotiation of & weekly group review of

“Guidelines for Respect” as alternative to “rules”

•Positive Interaction Style

•See “Collaborative/Elaborative Interaction Style”

•Use of pre-negotiated support scripts/interventions

•Collaboration with Behavior Specialists

GENERAL INTERVENTION SUPPORTS•Maintenance of weekly group routines

•Effectively trained staff and graduate student clinicians

•Positive, collaborative/elaborative, non-pedagogical interaction style

(i.e., peer to peer, staff to participant)

•Consistent, positive, antecedent-focused behavioral supports

•Pre-negotiated support scripts

•Culture of positive communication and support

•Weekly Routines

•Review of group goals/’Guidelines for Respect’

•Current Events discussion

•End of session review

•Environmental Supports

•Strategic reading organizer

•External graphic organizers

•Use of story support power point slides (see insert)

•Immediate access to internet resources

•Supportive cueing to ensure errorless learning

50 CENT WORDS DICTIONARY

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Ongoing Contextualized Collaborative Hypothesis-Ongoing Contextualized Collaborative Hypothesis-Testing Testing

Identify The Problem/Obstacle(s)Identify The Problem/Obstacle(s)

Formulate HypothesesFormulate Hypotheses(List potential supports

to facilitate comprehension/decoding)

Test HypothesesTest Hypotheses(Systematically, in group, one support

per week)

Select HypothesisSelect Hypothesis(Supports identified by clinician & selected by

group. Priorities determined by ease of

testing or most obvious)

GROUP FACILITATOR

Chapter 9 begins with Scout in another fightwith a boy from school. She is defendingherself from a rumor about her father. Thisis the first of Atticus’ legal cases thateffects Jem and Scout. Scout asks Atticusto explain why he is defending TomRobinson.

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•Predictable communication routines

•Aphasia-friendly (simplified, multi-modality) language

•Graphic representation of concepts

•Pre-programmed scripts & discussion outlines in

AAC devices

• Participant-directed individualized communication

trainings for peers & staff

Integrate all supports

deemed effective