Intensive Cognitive-communication Rehabilitation for College-bound

Intensive cognitive-communication rehabilitation for college-bound young adults with brain injury BACKGROUND • • • • • RESULTS Young adults (YA) are a frequently affected and growing group to suffer traumatic brain injury (TBI) and stroke.1,2 Acquired brain injury (ABI) often negatively impacts cognitive-linguistic function (e.g., reading), activity participation (e.g., following a class syllabus), and overall well-being (e.g., satisfaction with life as unenrolled/unemployed).3,4 Not surprisingly, YAs with ABI often struggle in an academic setting (e.g., ~80% of individuals with TBI).5 Comprehensive, contextualized cognitive rehabilitation (CR) programs target cognitive-linguistic constructs, teach compensatory strategies, and provide contexts for learning implementation. Such programs have resulted in significant gains in cognition, community integration and independence for individuals with ABI.6 Yet, to date, none of these programs have focused directly on supporting YAs with ABI who want to pursue college, while also incorporating all relevant principles of experience-dependent neural plasticity to maximize rehabilitation progress (i.e., repetition, salience, specificity of training, enriched environment, intensity, age).7 RESEARCH QUESTIONS RQ 1: Show gains in cognitive-linguistic functioning? n = 10 Controls showed no significant change in item-level accuracy on standardized cognitive linguistic assessments after a 12-week period without intervention (via McNemar’s tests; p >.05; not plotted) Summary: Yes. As the number of semesters in ICCR increased, participants’ scores on 2/4 tests of cognitive-linguistic function significantly improved. The lack of significant change on controls scores’ suggests the intervention resulted in the ICCR students’ gains. RQ 2: Exhibit progress in individual speech therapy? After an Intensive Cognitive-Communication Rehabilitation (ICCR) program, do ICCR students… • Show gains in cognitive-linguistic functioning? • Exhibit progress in individual speech therapy? • Show improved classroom performance? • Demonstrate increased participation and quality of life? METHODS Pre-treatment Sample Goal Post-treatment Sample Goal P1 Selective attention in a non-distracting Alternating attention in a non-distracting environment with moderate cues environment with minimal cues P3 1-5 minute sustained attention 5-10 minute sustained & selective attention P6 Write functional information at 2-3 Write functional information at a 5-6 paragraph level (i.e., email) paragraph level (i.e., article summary) P8 Read short sentence (i.e., 6 words) and Read short paragraph (i.e., 3 sentences) and match to picture answer Wh- questions P9 Recall 2-3 unassociated words given 5 Recall 3-4 unassociated words given 5 minute delay minute delay P10 Accurately spell 5/15 sight words using Accurately spell 12/15 sight words using phoneme-grapheme correspondence phoneme-grapheme correspondence RQ 3: Show improved classroom performance? Pretreatment Test Battery Posttreatment Test Battery Treatment Formal Assessments: (12 weeks) Cognitive-Linguistic Function • Western Aphasia Battery - Revised (WAB-R)8 • Scales of Cognitive and Communicative Ability for Neurorehabilitation (SCCAN)9 • Repeatable Battery for the Assessment of Neuropsychological Status (RBANS)10 • Discourse Comprehension Test (DCT)11 Participation and Quality of Life • Child and Adolescent Scale of Participation (CASP)12 • TBI-QOL13 and Neuro-QOL14 Informal Assessments: • Daily classroom performance (e.g., answering questions) • Performance on individual speech therapy goals (e.g., accurately spelling words) Summary: Not significantly over time. Positive behaviors (e.g., answering questions, asking questions, making comments accurately/appropriately) were significantly more common in the classroom than negative behaviors, but they did not increase significantly more than negative behaviors across the semester. Note: Showing Spring semester cohort data (n = 6) RQ 4: Demonstrate increased participation and quality of life? CASP (n = 6) * Note: 100 = full participation 80 20 Monday 10:00 Economics Lecture 1:00 2:00 3:00 Tuesday Biology Lecture Thursday Economics Lecture Other Activities BioIogy Lecture Review Review Review Review Practice Quiz ?’s Practice Quiz ?’s Practice Quiz ?’s Practice Quiz ?’s Lunch Lunch Lunch Lunch Statistics English Literature Statistics English Literature Tech Tech Tech Tech Take quizzes & finals Receive individual SLP targeting discrete skills & strategy training Attend sessions about college transition process Note: ~288 hours/semester; ICCR students may attend multiple semesters of the program until they are ready to transition to post-secondary education. Demographic Information Age ICCR students (n=10) Controls (n=2) 25.1 (4.1) 27.5 (6.4) MPO Etiology TBI = 6 62.8 Stroke = 3 (33.4) Tumor = 1 49 TBI = 1 (15.6) Stroke = 1 Sex PrePreEducation treatment treatment Level WAB RBANS M=7 F=3 14.0 (1.4) 70.3 (23.1) 52.8 (11.1) F=2 12.5 (0.7) 87.8 (4.9) 61.5 (13.4) Note: Mean (SD); MPO = months post onset; Pre-treatment WAB = Aphasia Quotient (out of 100; higher score = less severe); Pre-treatment RBANS = Total Index Score (Standard Score: Mean = 85; SD = 10) TBI-QOL T-scores (n = 3) Note: Mean = 50 SD = 10 70 60 50 40 30 20 10 0 0 Home Light = pre Dark = post Friday Neuro-QOL T-scores Note: Mean = 50 (n = 3) SD = 10 70 60 50 40 30 20 10 0 100 40 Sample Weekly Treatment Schedule Negative vs. Positive: ẞ = -7.63, SE = 1.26, t-value= -6.04, p < .001 Time*Behavior interaction: ẞ = -0.06, SE = 0.05, t-value = -1.07, p = 0.29 Inter-rater reliability: 25% of data was coded by a 2nd coder (70% reliable) = positive = negative 60 12:00 Summary: Yes. Students were working on more complex goals and/or with less clinician support by the end of the ICCR semester. They also progressed on personal goals (e.g., navigating campus), which they developed with the clinician to increase their independence. Note: Showing Spring semester cohort data (n = 6) Assessment 11:00 Timepoint significantly predicted score over time on the WAB and SCCAN (see figure). Neigh. & Comm. School Home & Comm. Living Total Score Light = pre Dark = post Light = pre Dark = post Note: Showing Spring semester cohort data (n = 6); QOL measures: Anxiety, Depression – Higher score worse; Cognition, Communication, Positive Affect – Higher score better. Of note, Neuro-QOL Communication is a raw score (Max = 25), as no t-score is available. No statistics conducted on QOL measures due to small n and slight differences between Neuro-QOL and TBI-QOL versions making it inappropriate to collapse across versions. Summary: Yes. ICCR students improved in the majority of participation metrics and significantly in the School domain. In terms of the QOL measures, pre- to post-treatment changes did not exceed the standard deviation. Yet, after ICCR, students demonstrated trends consistent with increased positive affect and communication, in addition to lower depression. DISCUSSION & FUTURE DIRECTIONS • Consistent with current principles of neuroplasticity, ICCR provided intensive, repetitive, specific and salient training on cognitive-linguistic function within an academic context. • ICCR students’ standardized cognitive-linguistic assessment scores significantly improved as the number of semesters in ICCR increased, suggesting a cumulative benefit of ICCR. • In terms of the classroom, ICCR students significantly improved in their participation at school (e.g., academic activities with other students). Furthermore, they contributed successfully in the classroom (e.g., answering questions accurately > inaccurately). Overall, the classroom environment was positive with limited inappropriate behaviors. • ICCR students also showed gains in individual speech therapy (i.e., complexity of goals increased by the end of semester) and quality of life (e.g., higher positive affect). • Corroborating our previous work,15 these findings support ICCR’s efficacy. Future work will investigate the specific cognitive-linguistic domains important for academic success that improve over time after ICCR and the neuroplasticity supporting such gains. SELECTED REFERENCES 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. https://www.cdc.gov/traumaticbraininjury/data/rates_ed_byage.html George et al. JAMA Neurol. 2017;74(6):695. Sinanović et al. Acta Clin Croat. 2011;50(1):79–94. Rabinowitz et al. Psychiatr Clin North Am. 2014;37(1):1–11. Kennedy et al. NeuroRehabilitation. 2008;23(6):511–520. 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