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.

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.

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.

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.

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.

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.

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.

Abstract Outcome studies have established that successful community living is compromised in the population of individuals with traumatic brain injury and chronic behavioural difficulties along with a co-occurring diagnosis of substance abuse and/or mental health disorder. Two studies are presented. The first was aimed at describing long-term outcome of a sample of individuals (N = 51) served by the New York State Department of Health TBI Medicaid Waiver Program. Each of the participants was diagnosed with TBI plus either substance abuse or a mental health disorder, or both. Because of significant behavioural challenges, all of the participants were in a restrictive living setting the year before enrolment in the waiver program (e.g., nursing or correctional facility). Data on community living arrangement, self-reported community integration experiences, and costs are presented. Results indicate that most of the participants (41 of the 46 who were alive and living in state) continued to live in the community 8 to 9 years after commencement of community support services. The participants' community integration responses were generally positive and cost data demonstrate substantial savings to the state for this cohort. Comparing prewaiver costs in residential settings with most recent (2005) costs for community supports, there was an average daily cost savings of US$137 per person for the 1996 cohort and US$144 per person for the 1997 cohort. The second study explored the use of project-oriented interventions and supports in an agency that provides community support services to this dual diagnosis population. Project-oriented services are described as meeting many needs common to this dual-diagnosis population. Clinical staff (N = 11) and a sample of waiver participants (N = 7) were surveyed. Results suggest that the use of personally meaningful projects can become a clinical habit for staff and that projects are generally judged by participants to be a meaningful use of time, and significant in giving them an opportunity to play an expert role and to help others.

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.

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.

AbstractUnsuccessful social communication after traumatic brain injury (TBI) is often a consequence of self-regulatory (executive function) impairments. The primary goal of this article is to describe an approach to intervention for individuals with self-regulatory impairments that is individualised, sensitive to context and to the role of everyday communication partners, and supported by personally compelling metaphors. After a brief review of the social communication outcome literature, an innovative approach to improving social competence is presented and illustrated. The article ends with a review of the evidence base for social skills and self-talk interventions.

Abstract Relatively little high-quality evidence is available that addresses interventions for children and adolescents with cognitive, academic, social, and or behavioural disorders associated with traumatic brain injury (TBI). However, important intervention themes can be derived from the available research with this population combined with research with (nominally) different disability populations as well as non-disability populations. This synthesis of research findings across populations is the primary goal of this chapter. Following a summary of existing pediatric TBI evidence reviews, a description of issues related to TBI as a disability category, and a discussion of the concept of evidence in clinical decision making, the chapter reviews relevant evidence related to assessment and to cognitive, educational, social skills, and behavioural interventions, as well as family and teacher training and support. The chapter ends with a list of areas for future research.

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.

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.