Efficacy of BETTER transitional care intervention for diverse patients with traumatic brain injury and their families: Study protocol of a randomized controlled trial.

OBJECTIVE: The purpose of this study is to examine the efficacy of BETTER (Brain Injury, Education, Training, and Therapy to Enhance Recovery) vs. usual transitional care management among diverse adults with traumatic brain injury (TBI) discharged home from acute hospital care and families. METHODS: This will be a single-site, two-arm, randomized controlled trial (N = 436 people, 218 patient/family dyads, 109 dyads per arm) of BETTER, a culturally- and linguistically-tailored, patient- and family-centered, TBI transitional care intervention for adult patients with TBI and families. Skilled clinical interventionists will follow a manualized protocol to address patient/family needs. The interventionists will co-establish goals with participants; coordinate post-hospital care, services, and resources; and provide patient/family education and training on self- and family-management and coping skills for 16 weeks following hospital discharge. English- and Spanish-speaking adult patients with mild-to-severe TBI who are discharged directly home from the hospital without inpatient rehabilitation or transfer to other settings (community discharge) and associated family caregivers are eligible and will be randomized to treatment or usual transitional care management. We will use intention-to-treat analysis to determine if patients receiving BETTER have a higher quality of life (primary outcome, SF-36) at 16-weeks post-hospital discharge than those receiving usual transitional care management. We will conduct a descriptive, qualitative study with 45 dyads randomized to BETTER, using semi-structured interviews, to capture perspectives on barriers and facilitators to participation. Data will be analyzed using conventional content analysis. Finally, we will conduct a cost/budget impact analysis, evaluating differences in intervention costs and healthcare costs by arm. DISCUSSION: Findings will guide our team in designing a future, multi-site trial to disseminate and implement BETTER into clinical practice to enhance the standard of care for adults with TBI and families. The new knowledge generated will drive advancements in health equity among diverse adults with TBI and families. TRIAL REGISTRATION: NCT05929833.

The BETTER Traumatic Brain Injury Transitional Care Intervention: A Feasibility Study.

This study aimed to investigate the feasibility, acceptability, and clinical outcome measures of BETTER (Brain Injury Education, Training, and Therapy to Enhance Recovery), a culturally tailored traumatic brain injury (TBI) transitional care intervention, among diverse younger adult patients with TBI (age 18-64) and their caregivers. Trained clinical interventionists addressed patient/family needs; established goals; coordinated post-hospital care and resources; and provided patient/family training on self- and family-management coping skills. Fifteen dyads enrolled (N = 31, 15 patients, 16 caregivers). All completed baseline data; 74.2% (n = 23; 10 patients, 13 caregivers) completed 8-week data; 83.8% (n = 26; 13 each) completed 16-week data. Approximately 38% (n = 12, 3 patients, 9 caregivers) completed acceptability data, showing positive experiences (mean = 9.25, range 0-10; SD = 2.01). Overall and mental quality of life (QOL) scores did not differ over time but physical QOL scores did improve over time (baseline: 30.3, 8 weeks: 46.5, 16 weeks: 61.6; p = 0.0056), which was considered to be a suitable outcome measure for a future trial. BETTER is a promising intervention with implications to improve TBI care standards. Research is needed to determine efficacy in a randomized trial.

Predictors of cognitive gains during inpatient rehabilitation for older adults with traumatic brain injury.

INTRODUCTION: Traumatic brain injury (TBI) among older adults is increasing and can affect cognition. To effectively meet the rehabilitation needs of older adults, a clearer picture is needed of patient-, clinical-, and facility-level characteristics that affect cognitive recovery during inpatient rehabilitation facility (IRF) stays. OBJECTIVE: To identify patient, clinical, and facility factors associated with cognitive recovery among older adults with TBI who received IRF care. DESIGN: Secondary data analysis. SETTING: Uniform Data System for Medical Rehabilitation-participating IRFs in the United States. PATIENTS: Patients were 65 to 99 years of age at IRF admission for TBI. Participants received IRF care between 2002 and 2018 (N = 137,583); 56.3% were male; 84.2% were white; mean age was 78.7 years. MAIN OUTCOME MEASURE: Change in Functional Independence Measure Cognitive Score (FIM-Cognitive) from IRF admission to discharge, categorized as favorable (FIM-cognitive score gains ≥3 points) or poor (FIM-cognitive score gains <3 points) cognitive outcomes. INTERVENTIONS: Not applicable. RESULTS: Patients had greater odds of favorable cognitive recovery if they were female (adjusted odds ratio [aOR] 1.05, 95% confidence interval [CI] 1.05-1.08), had higher motor functioning at IRF admission (aOR 1.03, 95% CI 1.03-1.04), longer length of stay (aOR 1.07, 95% CI 1.06-1.07), or received care at a freestanding IRF (vs. hospital rehab unit) (aOR 1.57, 95% CI 1.52-1.61). Patients who were older (aOR 0.99, 95% CI 0.98-0.99), Black (aOR 0.79, 95% CI 0.75-0.83), Hispanic or Latino (aOR 0.97, 95% CI 0.91-1.02), or were part of another racial or ethnic group (aOR 0.85, 95% CI 0.81-0.90) (vs. White), had high-cost comorbid conditions (aOR 0.71, 95% CI 0.65-0.76), or who had higher cognitive functioning at IRF admission (aOR 0.90, 95% CI 0.90-0.91) had lower odds of favorable cognitive recovery. CONCLUSIONS: Patient (age, sex, race, ethnicity), clinical (level of functioning at IRF admission, length of stay) and facility (e.g., freestanding IRF) factors contributed to the cognitive recoveries of older adults during IRF stays.

Sex and Racial/Ethnic Differences in Within-Stay Readmissions During Inpatient Rehabilitation Among Patients With Traumatic Brain Injury.

OBJECTIVE: The aim of the study was to determine the association of sex and race/ethnicity with acute hospital readmissions ("within-stay readmissions") during inpatient rehabilitation facility care versus patients discharged home without a within-stay readmission among traumatic brain injury patients. DESIGN: The study used a secondary analysis ( N = 210,440) of Uniform Data System for Medical Rehabilitation data using multiple logistic regression. RESULTS: Within-stay readmissions occurred for 11.79% of female and 11.77% of male traumatic brain injury patients. Sex-specific models identified insurance, comorbidities, and complications factored differently in likelihood of within-stay readmissions among female than male patients but association of all other factors were similar per group. Within-stay readmissions differences were more pronounced by race/ethnicity: White, 11.63%; Black, 11.32%; Hispanic/Latino, 9.78%; and other, 10.61%. Descriptive bivariate analysis identified racial/ethnic patients with within-stay readmissions had greater days from traumatic brain injury to inpatient rehabilitation facility admission (White, 17.66; Black, 21.70; Hispanic/Latino, 23.81; other, 20.66) and lower admission cognitive and motor function. Factors differed across models predicting within-stay readmissions for race/ethnic groups; age, admission motor and cognitive function, complications, and length of stay were consistent across groups. CONCLUSIONS: This study demonstrates disparities by race/ethnicity for inpatient rehabilitation facility within-stay readmissions among traumatic brain injury patients and factors predictive of this potentially preventable outcome by sex and race/ethnicity. Findings could inform care planning and quality improvement efforts for TBI patients.

Design, methods, and baseline characteristics of the Brain Injury Education, Training, and Therapy to Enhance Recovery (BETTER) feasibility study: a transitional care intervention for younger adult patients with traumatic brain injury and caregivers.

OBJECTIVES: We developed a patient- and family-centered traumatic brain injury (TBI) transitional care intervention, called BETTER (Brain Injury Education, Training, and Therapy to Enhance Recovery), to improve quality of life (via SF-36) of younger TBI patients of different racial groups discharged home from acute hospital care and caregivers. We describe our design, methods, and baseline characteristics for our feasibility study. METHODS: We co-developed BETTER with input from key stakeholders (TBI patients and caregivers, healthcare providers, and interdisciplinary research team members). BETTER is guided by the Individual and Family Self-Management Theory, our team's prior research, as well as literature used to support, educate, and train patients and families recovering from TBI and other conditions. The intervention is delivered by trained clinical interventionists (transitional care managers), beginning 24-72 h pre-discharge to 16 weeks post-discharge. BETTER offers tailored transitional care support to patient/family dyads, including assessing needs; establishing goals; coordinating post-hospital care, services, and resources; and providing patient/family education and training on brain injury coping skills. The majority of the intervention is delivered remotely via phone and remote video conferencing platform (Clinicaltrials.gov: NCT04584554). RESULTS: We enrolled 15 dyads (N = 31, 15 patients, 16 caregivers) in this single arm, single center feasibility study. Most patients were men (n = 11, 73.33%), had a mean age of 39.07 (SD: 15.15), and were Black (n = 9, 60%), White (n = 5, 33.3%), or American Indian (n = 1, 0.66%). Injury severities were mild (n = 6, 40%), moderate (n = 4, 26.6%) or severe (n = 5, 33.33%). Most patients were insured (n = 10; 66.7%), had a high school education (n = 6; 40%); and earned $30,000 or less per year (n = 11; 73.3%). Most caregivers were married (n = 9, 56.25%) women (n = 14, 87.5%) with a mean age of 43.38 (SD: 10.45) and were Black (n = 8, 50%), White (n = 7, 43.75%), or American Indian (n = 1, 0.62%). Most caregivers identified as the spouse (n = 7; 43.75%) or parent (n = 6; 37.5%) of the patient. CONCLUSIONS: BETTER is among the first TBI transitional care intervention to address needs/preferences for younger TBI patients of different racial groups after discharge home from acute hospital care and families. Findings can be used to inform future work.

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.

Working Memory for Emotions in Adolescents and Young Adults with Traumatic Brain Injury.

This preliminary study investigated the interaction between working memory and social cognition in adolescents and young adults with traumatic brain injury (TBI). It was hypothesized that participants with or without TBI would better recognize social information when working memory or social cognitive load was low, and that adolescents and young adults with TBI would be more affected by increased cognitive demand than their uninjured peers. Eight adolescents and young adults with complicated mild-severe TBI (aged 14-22 years) and eight age- and sex-matched typically developing (TD) adolescents completed computer-based n-back tasks requiring recognition of either face identity or facial affect, with 0-back, 1-, and 2-back conditions. The TBI group had lower scores overall than the TD group, and scores for both groups were lower for affect recognition than identity recognition. Scores for both groups were lower in conditions with a higher working memory load. There was a significant group-by-working memory interaction, with larger group differences in high-working memory conditions. Study results and their potential implications for social outcomes are discussed.

Age- and sex-specific predictors of inpatient rehabilitation facility discharge destination for adult patients with traumatic brain injury.

OBJECTIVE: : To determine age- and sex-specific predictors of discharge destination among patients with traumatic brain injury (TBI) receiving inpatient rehabilitation facility (IRF) care. DESIGN: : Secondary analysis of Uniform Data System for Medical Rehabilitation data. METHODS: : Logistic regression of patients (N = 221,961) age ≥18, TBI diagnosis, admitted to IRF between 2002 and 2018. OUTCOME: : Discharge destination (subacute vs. home/community settings). RESULTS: : Approximately 16% were discharged to subacute vs. 84% home. Younger versus older adults had lower odds of subacute discharge [OR = 0.72; 95% CI: 0.69, 0.76]. Younger females had lower odds of subacute discharge (vs. home) than older females [OR = 0.68; 95% CI: 0.63, 0.74]; younger males had lower odds of subacute discharge (vs. home) than older males [OR = 0.74; 95% CI: 0.70, 0.78]. Younger females versus younger males had lower odds of subacute discharge (vs. home) [OR = 0.83; 95% CI: 0.79, 0.87]. Older females versus older males had lower odds of subacute discharge (vs. home) [OR = 0.93; 95% CI: 0.90, 0.97]. Predictors of discharge destination for age- and sex-stratified groups varied. CONCLUSIONS: : Younger (vs. older) and female (vs. male) patients had lower odds of subacute discharge vs. home.

Inpatient rehabilitation facility discharge destination among younger adults with traumatic brain injury: differences by race and ethnicity.

OBJECTIVE: : To determine the association of race and ethnicity with discharge destination among patients with traumatic brain injury (TBI) receiving inpatient rehabilitation facility (IRF) care. DESIGN: Secondary analysis using Uniform Data System for Medical Rehabilitation data. METHODS: : Patients (N = 99,614) diagnosed with TBI, age 18-64, admitted for IRF care between 2002 and 2018. Logistic regression was used to analyze data. OUTCOME: : Discharge destination (home/community vs. subacute settings). RESULTS: : Most younger adults (age 18-64) with TBI were discharged home (89.24%) after IRF care vs. subacute (10.76%). Of those discharged home, 63.16% were white, 10.42% Black, 8.94% Hispanic/Latino, and 6.72% other races/ethnicities. After adjusting for covariates, patients who were Hispanic/Latino [OR = 1.26; 95% CI: 1.15, 1.37] and other race/ethnicities [OR = 1.10; 95% CI: 1.00, 1.21] (vs. White) had higher odds of discharge home vs. subacute. There was no difference in discharge destination for Black patients (vs. white). Predictors of discharge destination for groups stratified by race/ethnicity varied. CONCLUSIONS: : Younger patients with TBI who were Hispanic/Latino or other races/ethnicities (vs. white) were more likely to go home vs. subacute. Findings can be used to inform IRF planning, resource allocation, and transitional care planning.

Transitions of care interventions to improve quality of life among patients hospitalized with acute conditions: a systematic literature review.

BACKGROUND: Although transitional care interventions can improve health among patients hospitalized with acute conditions, few interventions use patient quality of life (QOL) as the primary outcome. Existing interventions use a variety of intervention components, are not effective for patients of all races and ethnicities, do not address age-related patient needs, and do not incorporate the needs of families. The purpose of this study was to systematically review characteristics of transitional care intervention studies that aimed to improve QOL for younger adult patients of all race and ethnicities who were hospitalized with acute conditions. METHODS: A systematic review was conducted of empirical literature available in PubMed, Embase, CINAHL, and PsycINFO by November 19, 2019 to identify studies of hospital to home care transitions with QOL as the primary outcome. Data extraction on study design and intervention components was limited to studies of patients aged 18-64. RESULTS: Nineteen articles comprising 17 studies met inclusion criteria. There were a total of 3,122 patients across all studies (range: 28-536). Populations of focus included cardiovascular disease, chronic obstructive pulmonary disease, stroke, breast cancer, and kidney disease. Seven QOL instruments were identified. All interventions were multi-component with a total of 31 different strategies used. Most interventions were facilitated by a registered nurse. Seven studies discussed intervention facilitator training and eight discussed intervention materials utilized. No studies specified cultural tailoring of interventions or analyzed findings by racial/ethnic subgroup. CONCLUSIONS: Future research is needed to determine which intervention components, either in isolation or in combination, are effective in improving QOL. Future studies should also elaborate on the background and training of intervention facilitators and on materials utilized and may also consider incorporating differences in culture, race and ethnicity into all phases of the research process in an effort to address and reduce any health disparities.

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.

Modality Effects on Lexical Encoding and Memory Representations of Spoken Words.

OBJECTIVES: The present study investigated presentation modality differences in lexical encoding and working memory representations of spoken words of older, hearing-impaired adults. Two experiments were undertaken: a memory-scanning experiment and a stimulus gating experiment. The primary objective of experiment 1 was to determine whether memory encoding and retrieval and scanning speeds are different for easily identifiable words presented in auditory-visual (AV), auditory-only (AO), and visual-only (VO) modalities. The primary objective of experiment 2 was to determine if memory encoding and retrieval speed differences observed in experiment 1 could be attributed to the early availability of AV speech information compared with AO or VO conditions. DESIGN: Twenty-six adults over age 60 years with bilateral mild to moderate sensorineural hearing loss participated in experiment 1, and 24 adults who took part in experiment 1 participated in experiment 2. An item recognition reaction-time paradigm (memory-scanning) was used in experiment 1 to measure (1) lexical encoding speed, that is, the speed at which an easily identifiable word was recognized and placed into working memory, and (2) retrieval speed, that is, the speed at which words were retrieved from memory and compared with similarly encoded words (memory scanning) presented in AV, AO, and VO modalities. Experiment 2 used a time-gated word identification task to test whether the time course of stimulus information available to participants predicted the modality-related memory encoding and retrieval speed results from experiment 1. RESULTS: The results of experiment 1 revealed significant differences among the modalities with respect to both memory encoding and retrieval speed, with AV fastest and VO slowest. These differences motivated an examination of the time course of stimulus information available as a function of modality. Results from experiment 2 indicated the encoding and retrieval speed advantages for AV and AO words compared with VO words were mostly driven by the time course of stimulus information. The AV advantage seen in encoding and retrieval speeds is likely due to a combination of robust stimulus information available to the listener earlier in time and lower attentional demands compared with AO or VO encoding and retrieval. CONCLUSIONS: Significant modality differences in lexical encoding and memory retrieval speeds were observed across modalities. The memory scanning speed advantage observed for AV compared with AO or VO modalities was strongly related to the time course of stimulus information. In contrast, lexical encoding and retrieval speeds for VO words could not be explained by the time-course of stimulus information alone. Working memory processes for the VO modality may be impacted by greater attentional demands and less information availability compared with the AV and AO modalities. Overall, these results support the hypothesis that the presentation modality for speech inputs (AV, AO, or VO) affects how older adult listeners with hearing loss encode, remember, and retrieve what they hear.

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.

Facial emotion recognition of older adults with traumatic brain injury.

OBJECTIVES: The objective of this study was to examine the effects of traumatic brain injury (TBI) and age on facial emotion recognition abilities in adults. Age and TBI were expected to have negative effects on emotion recognition and a TBI by age interaction was hypothesized such that older adults with TBI would have the lowest emotion recognition scores. METHODS: A prospective cohort study was conducted. Participants were 26 adults with moderate-severe TBI (13 older and 13 younger) and 26 uninjured peers matched for age, sex, and education. Emotion recognition was measured using the Emotion Recognition Task, which is comprised of dynamically morphed facial expressions of the six basic emotions, presented at different intensity levels. RESULTS: TBI and older age were associated with poorer recognition of both subtle and intense expressions, but only for expressions of anger and sadness. There was no interaction of age and TBI. CONCLUSIONS: Results add to the growing evidence of emotion recognition impairments after TBI, particularly for select negative emotions, and extend this finding to adults over the age of 60. Further research is needed to better understand social cognitive effects of TBI across the adult lifespan.

Cognitive task demands and discourse performance after traumatic brain injury.

BACKGROUND: Social communication problems are common in adults with traumatic brain injury (TBI), particularly problems in spoken discourse. Social communication problems are thought to reflect underlying cognitive impairments. AIMS: To measure the contribution of two cognitive processes, executive functioning (EF) and theory of mind (ToM), to the communication of adults with TBI, and to investigate the relationships between discourse performance and potential communication partners' perceptions. METHODS & PROCEDURES: Twenty-one adults with moderate-to-severe TBI and 23 uninjured adults completed a discourse task in which EF and ToM demands were manipulated across three conditions: baseline, high-EF and high-ToM. Dependent variables were fluency (for EFs), number of mental state terms (MSTs; for ToM) and speech rate. Discourse from high-EF/ToM conditions was judged by naïve raters for social acceptability. OUTCOMES & RESULTS: The TBI group produced significantly fewer MSTs than the comparison group across conditions and also spoke at a slower rate, and there were significant effects of condition on both measures (MST: high-EF < baseline = high-ToM; speech rate: high-EF < high-ToM < baseline). There were no significant between-groups differences in fluency or interaction of fluency with condition. MST use and fluency were associated with social acceptability ratings. CONCLUSIONS & IMPLICATIONS: Results added further evidence of social communication problems in adults with TBI and demonstrated that discourse behaviours may negatively affect how a speaker is perceived. Results also indicated that task manipulations can affect discourse performance, suggesting that general cognitive demands may influence social communication after TBI.

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.

Theory of mind: mechanisms, methods, and new directions.

Theory of Mind (ToM) has received significant research attention. Traditional ToM research has provided important understanding of how humans reason about mental states by utilizing shared world knowledge, social cues, and the interpretation of actions; however, many current behavioral paradigms are limited to static, "third-person" protocols. Emerging experimental approaches such as cognitive simulation and simulated social interaction offer opportunities to investigate ToM in interactive, "first-person" and "second-person" scenarios while affording greater experimental control. The advantages and limitations of traditional and emerging ToM methodologies are discussed with the intent of advancing the understanding of ToM in socially mediated situations.

Effects of social cognitive demand on Theory of Mind in conversations of adults with traumatic brain injury.

BACKGROUND: A requisite skill for successful conversation is the ability to adjust one's language according to contextual factors. AIMS: This study examined one aspect of language use in context-the use of mental-state terms, i.e. words that communicate thoughts, beliefs or feelings-in conversations between adult males with and without traumatic brain injury (TBI) and familiar partners. METHODS & PROCEDURES: Participants were five males in the chronic stage of recovery following severe TBI and five male peers matched for age, conversing with friends. Conversational context was manipulated using conversation starters that were designed to induce differing levels of self-disclosure or intimacy, with the expectation that mental-state term use would increase when participants talked about more intimate topics. OUTCOMES & RESULTS: Participants in both groups used more mental-state terms in more intimate conversations; however, adults with TBI did not increase their mental-state term use to the same extent as matched peers. Adults with TBI also used a significantly different pattern of mental-state term types across intimacy levels as compared with peers. CONCLUSIONS & IMPLICATIONS: These quantitative and qualitative differences may contribute to social conversation problems of adults with TBI.

Beyond utterances: distributed cognition as a framework for studying discourse in adults with acquired brain injury.

Considerable effort has been directed at understanding the nature of the communicative deficits observed in individuals with acquired brain injuries. Yet several theoretical, methodological, and clinical challenges remain. In this article, we examine distributed cognition as a framework for understanding interaction among communication partners, interaction of communication and cognition, and interaction with the environments and contexts of everyday language use. We review the basic principles of distributed cognition and the implications for applying this approach to the study of discourse in individuals with cognitive-communication disorders. We also review a range of protocols and findings from our research that highlight how the distributed cognition approach might offer a deeper understanding of communicative mechanisms and deficits in individuals with cognitive communication impairments. The advantages and implications of distributed cognition as a framework for studying discourse in adults with acquired brain injury are discussed.