Intervention for Moderate to Severe TBI
Speech, Language, Cognitive Interventions
When the child returns home following hospitalization and rehabilitation from a
moderate to severe traumatic brain injury, he is usually functioning at a
level 6 or higher on the Rancho Los Amigos Scale of Cognitive Recovery.The
following treatment suggestions offer ideas appropriate to those levels.
Intervention strategies for the more severely involved child are
addressed in the section Very Severe/Catastrophic TBI.
For Oral-Motor, Speech and Voice Production Problems
If the child exhibits a dysarthria, exercises requiring active involvement in range
of movement, strength and speed of movement of the muscles for speech are appropriate
at level 6 and above.The child will likely return home with a home program of exercises
designed specifically for his needs. It is important to be aware that both muscle
weakness and cognitive deficits may be involved in the speech production
problems that the child exhibits. Monitoring for fatigue as well as attention
and comprehension are all important. The child's articulation may vary depending
on how tired he is, when he last took a certain medication, and/or how well he is
processing the directions you are giving. In some cases his slurred speech may not be
entirely due to muscle weakness or decreased coordination but rather fatigue, attention
or medication effects as well.
Cognition can also affect the loudness of the child's voice. He may have coexisting muscle weakness
that affects respiration and loudness and/or he may also have a poorly functioning self-monitoring
system that does not provide him with the feedback needed to monitor his vocal production accurately.
Vocal prosody is commonly altered in these cases. Social pragmatic communication
skills related to turn-taking, eye contact, listening, and topic maintenance
are also often affected.Videotaping the child so that he can receive feedback for these
difficulties can be very effective.
Generally, language disturbances are a reflection of the impaired cognition, and once the
confusion and disorganization improves, the child's pre-injury language
emerges. In certain cases, when the damage is focal to the area of the speech and
language center of the brain, the child could experiences more specific problems related
to word-finding difficulties, naming problems, comprehension, reading and writing problems.
For Cognitive Linguistic Problems
Ideas for Structuring Speech Pathology Sessions
When the child is at a Level 6 on the RLA Scale…
Treatment sessions should be both group and individual and held on a daily
basis. Length of time should be 30-60 minutes with breaks at intervals appropriate
to his sustained attention abilities. The breaks could include a
physical activity such as a walk, stretching exercises, etc. The goals of treatment
would be to increase ability to sustain attention to a task, show selective attention
to a task in a distracting environment, improve immediate and recent memory through use of
compensatory strategies and improve thought organization abilities.
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Attention: Provide simple visual-motor tasks, visual discrimination and auditory discrimination tasks and
work towards being able to independently sustain attention for 60 minutes. These attention
tasks should help to increase the quality and duration of attention.
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Immediate Memory: Visual-verbal tasks could involve recall of letters or numbers or
combinations of letters and numbers; recall of word series (related and
unrelated) read; recall of pictures shown; recall of information from a short
paragraph read. Expect general information initially and increased detail as child
improves. Auditory tasks could involve recall of sentences, simple to complex; recall
series of numbers heard (up to 7); recall of information from paragraph read to him
(general information expected initially and then increased detail). Use of cues may be needed
initially, and then gradually withdrawn.
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Orientation: Use assignment book or daily log to record scheduled events,
classes and activities. The child may need help filling in and referring to the book
initially, but gradually this compensatory strategy should be independently used.
Information in the log should also include reminders of his injury, when it happened, why
he needs to use the book, teacher's names and any other important information.
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Thought Organization: Fill in missing letters and numbers in words and
sequences; coding activities; card sequencing activities; fill in the blank language
tasks; categorizing tasks building from general to specific; organize concrete routine
events including items needed and steps in the process.
When the child is at a Level 7 on the RLA Scale…
Treatment sessions should be both group and individual. Individual cognitive sessions,
1 hour 3 times per week. Group sessions, 1 hour 2 times per week and Independent work,
1 hour daily. Goals of treatment at this level involve improving ability to retain, store,
retrieve, organize and integrate information, progressively increasing the length and
complexity; improve thought organization, reasoning and problem solving; improve insight
into deficits, judgement and appropriate goal formulation.
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Memory and Organization: Activities for visual-verbal retention could
involve reading stories of increasing length; first retaining general, then more
specific information. Progress from multiple choice, to true/false, to fill-in-the
blank, to summaries answering who, what, when, where, why. Auditory-verbal retention
could involve similar activities from audiotapes or spoken. Gradually increase
the speed of the information presented. Independent study work could include
summarizing items from newscast or newspaper articles. It is also important to maintain
assignment/memory book/daily log at this level.
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Thought Organization, Reasoning, Problem Solving: Appropriate activities at
this level would be story completion activities, describing likenesses and differences,
detecting absurdities in statements, interpreting proverbs and idioms, and assessing
potentially dangerous situations. The child should be involved in planning as well as
carrying out extracurricular activities and evaluation of his performance.
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Insight, Judgement, Goal Formulation: It is important to provide the child with
information regarding his injury that is consistent with his developmental
level and levels of comprehension and retention. This information should include how
it has affected him physically, cognitively, socially and emotionally. Any ways to
graphically show goals and progress towards these goals is also important. Rationale for
each goal needs to be explained at the child's level as well.
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Psychosocial: Feelings need to be addressed as well as coping
behaviors to deal with the feelings. Identifying and sharing feelings of isolation,
despair, denial, etc. and discussing appropriate solutions will help the child
develop goals and adjust.
When the child is at levels 8,9,10 on the RLAH Scale…
Both Group and Individual sessions continue to be appropriate at these levels. Length
of sessions will depend on the goals of treatment related to independent work required.
General goals of treatment would be related to improving attention, memory and executive
functions.
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Attention: The areas of selective attention, alternating attention and divided
attention are focused on at this point. Working on tasks requiring attention in
distracting environments both auditory and visual is recommended. Tasks involving
switching from one modality to another or stopping with an interruption and then
restarting from where he left off are also used. The ultimate goal is to gradually work towards handling more
than one thing at a time. Opportunities to work in the school
office answering the phone, making copies, taking and delivering messages, counting
attendance or giving PA announcements could be used as very therapeutic activities.
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Memory: Both declarative and semantic memory is addressed at this time.
Declarative memory is the type most often disturbed in brain injury. It requires a
conscious level of awareness and ability to report events and give instructions.
It is often the least amenable to treatment and therefore augmentative compensatory
strategies are developed initially. At this point in recovery, a weaning process
is used to decide which strategies can be withdrawn and which need to continue to
be integrated into the student's everyday living. Semantic memory refers to those
things that the student already knows but doesn't really know when or how he learned
them. It involves knowledge of word meanings, groups of ideas and information.
Repetition and use of compensatory memory aids are useful in training this type of memory.
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Executive Functions: Goal selection, planning, initiation, self-regulation
and use of feedback are all a focus of this area of treatment. Working towards spending
time working in the school office offers a perfect opportunity to develop these skills.
The student has an opportunity to decide what he will work toward on the job (attention,
memory, organization, etc.), plan how he will do the job, initiate the appropriate
actions to complete the job, monitor himself on the job and make corrections and
receive feedback from others in order to make improvements.