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THE EFFECTS OF COGNITIVE REHABILITATION ON THE
REMEDIATION OF MEMORY, ATTENTION, AND SOCIO-
BEHAVIORAL DEFICITS FOR INDIVIDUALS WITH
TRAUMATIC BRAIN INJURY: A META-ANALYSIS OF THE
LITERATURE FROM 1980 - 2003

presented by

GEORGE PATRICK ALEXANDER PARRIS

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THE EFFECTS OF COGNITIVE REHABILITATION ON THE REMEDIATION OF
MEMORY, ATTENTION, AND SOCIO-BEHAVIORAL DEF ICITS FOR
INDIVIDUALS WITH TRAUMATIC BRAIN INJURY:

A META-ANALYSIS OF THE LITERATURE FROM 1980 —— 2003

By

George Patrick Alexander Parris

A DISSERTATION

Submitted to
Michigan State University
in partial ﬁilﬁllment of the requirements
for the degree of

DOCTOR OF PHILOSOPHY
Department of Counseling, Educational Psychology & Special Education

2005

ABSTRACT
THE EFFECTS OF COGNITIVE REHABILITATION ON THE REMEDIATION OF
MEMORY, ATTENTION, AND SOCIO-BEHAVIORAL DEFICITS IN
INDIVIDUALS WITH TRAUMATIC BRAIN INJURY:
A META-ANALYSIS OF THE LITERATURE FROM 1980 -2003
By
George Patrick Alexander Parris

The purpose of this dissertation is to critically evaluate the effectiveness of cognitive
rehabilitation interventions on the remediation of memory, attention, and socio-
behavioral deﬁcits for individuals with traumatic brain injury. Cognitive rehabilitation as
an intervention is relatively new and although it is widely used with individuals with TBI,
insufﬁcient large-scale research has been conducted supporting its efficacy. While some
studies have reported improved performance on memory, attention, and socio-behavioral
deficits, methodological inadequacies and inconsistent findings have prevented the
isolation of speciﬁc treatment effects as well as the generalization of the procedures. The
impact of treatment with cognitive remediation strategies appears to be facilitated by
variables that affect the natural recovery process such as severity of injury. As such, it
has been suggested that greater attention be given to research design issues and to the
consistent reporting of subject variables known to affect the natural recovery of cognitive
functions. In this dissertation, meta-analytic statistical procedures were used to determine
the effectiveness of cognitive rehabilitation interventions in the remediation of memory,
attention, and socio-behavioral deficits in individuals with TBI. A literature search was

done and a total of 465 published studies were located on cognitive rehabilitation

interventions and on TBI. From this a total of 248 studies were eliminated from the data

analysis and the remaining 217 studies were used in the meta-analysis. Of these meta-
analytic procedures were used to review 120 articles on memory remediation, 67 articles
were used in the analysis of attention remediation, and 30 articles were used in the
analysis of socio-behavioral deﬁcits. Results of the meta-analysis show that cognitive
rehabilitation intervention is positively correlated with the remediation of memory,

attention, and socio-behavioral deﬁcits following TBI.

DEDICATION
This manuscript is dedicated to
My loving and supportive mother
Enid Parris-Bond
For always being a positive inﬂuence in my education throughout my elementary years in
Guyana, South America and in my secondary and university years in Canada and the
United States of America.
In addition, I am dedicating this manuscript to
My loving and patient wife
Carol Madgalee Parris
For her encouragement and support throughout the years.
Finally, I dedicate this manuscript to
My loving children, Kiswana, Khalil, and Maia

For understanding why daddy was busy for so long.

iv

ACKNOWLEDGEMENTS

In my journey there were many mentors along the way, and I was fortunate to
have had a few terrific ones. I would like to thank Dr. Nancy Crewe for without her
enduring support, understanding, and patience, this process would have been frustrating
and just an academic exercise. I deeply appreciated her guidance, encouragement, and
knowledge throughout this process. I would also like to extend a sincere thanks to my
committee members, Dr. Michael Leahy and Dr. Robbie Steward for their support and
encouragement. In addition, I must thank Dr. John Kosciulek for agreeing to be on my
team with such short notice and Dr. Betsy Becker who was instrumental in assisting me
in understanding the concept of meta analysis.

We are fortunate if we have friends and families that are understanding during
times that demand time away from them. As such, I must sincerely thank everyone who
supported and encouraged me to move forward as I tried to achieve my goals.

Finally, there are few words that are capable of articulating my gratitude to my
family for their unfailing and endless support over the years that I have been working at
achieving this goal. My beautiful and loving wife, Carol, has stood by my side through
my entire doctoral program with unwavering support. My children, Kiswana, Khalil, and
Maia for encouraging me with their smiles, kisses, and hugs. In addition, I acknowledge

the support, words of encouragement, and interest in my journey from my in-laws.

TABLE OF CONTENTS

LIST OF TABLES ............................................................................................... viii
CHAPTER 1 ............................................................................................................ 1
INTRODUCTION ................................................................................................... 1
Epidemiology ...................................................................................................... 1
Sequelae of Traumatic brain Injury .................................................................... 5
Threats to Employment ....................................................................................... 7
Statement of the Problem .................................................................................... 8
Purpose of the Study ......................................................................................... 11
Signiﬁcance of the Study .................................................................................. 12
Deﬁnitions of Terms ......................................................................................... 14
CHAPTER 2
REVIEW OF THE LITERATURE ....................................................................... 19
Overview of Traumatic Brain Injury ................................................................ 19
Recovery after Traumatic Brain Injury .......................................................... 21
Etiology of Symptoms ................................................................................... 28
Sequelae of Traumatic Brain Injury .................................................................. 36
Physical Deﬁcits .............................................................................................. 37
Cognitive Deﬁcits ............................................................................................ 39
Psychosocial Deﬁcits ....................................................................................... 41
Remediation of Memory Deﬁcits .................................................................... 49
Remediation of Attention Deficits ................................................................... 57
Remediation of Socio-behavioral Deﬁcits ....................................................... 71
Vocational Outcomes Studies .......................................................................... 77
Cognitive Rehabilitation .................................................................................. 80
Deﬁning Cognitive Rehabilitation .............................................................. 82
Historic Perspective of Cognitive Rehabilitation ....................................... 85
Theoretical Foundations Underpinning Cognitive Rehabilitation .............. 87
Concerns Pertaining to Cognitive Rehabilitation as an
Intervention Strategy ................................................................................... 91
Service Delivery .......................................................................................... 92
Generalizability ........................................................................................... 92
Usefulness of Cognitive Rehabilitation ...................................................... 93
CHAPTER 3
DESIGN AND METHODOLOGY ...................................................................... 98
Collecting the Data ........................................................................................ 100
Criteria for Inclusion / Population ................................................................. 102
Coding Instrument .................................................................................... 103
Statistical Conversions ................................................................................... 107

vi

CHAPTER 4

INVESTIGATION AND RESULTS .................................................................. 110
Introduction to Cognitive Rehabilitation of Memory Deﬁcits in
Individuals with TBI ...................................................................................... 111
Cognitive Rehabilitation of Memory Deﬁcits in Individuals with
TBI Study Characteristics .............................................................................. 112
Cognitive Rehabilitation of Memory Deﬁcits in Individuals with TBI
Subject Characteristics ................................................................................... 116
Cognitive Rehabilitation of Memory Deficits in Individuals with
TBI Statistical Results: Acceptance of Rejection of the Hypothesis ............. 118
Introduction to Cognitive Rehabilitation of Attention Deﬁcits in
Individuals with TBI ...................................................................................... 127
Cognitive Rehabilitation of Attention Deficits Following TBI:
Study Characteristics ..................................................................................... 127
Cognitive Rehabilitation of Attention Deﬁcits in Individuals with TBI:
Subjects Characteristics ................................................................................. 131
Cognitive Rehabilitation of Individuals with Attention Deﬁcits
following a TBI: Acceptance or Rejection of the Hypothesis ....................... 133
Introduction to Cognitive Rehabilitation of Socio-behavioral Deﬁcits
in Individuals with TBI .................................................................................. 141
Cognitive Rehabilitation of Socio-behavioral Deﬁcits Following TBI:
Study Characteristics ..................................................................................... 142
Cognitive Rehabilitation of Socio-behavioral Deficits in Individuals with
TBI: Subjects Characteristics ......................................................................... 145
Cognitive Rehabilitation of Individuals with Socio—behavioral Deﬁcits
following a TBI: Acceptance or Rejection of the Hypothesis ....................... 147
CHAPTER 5
CONCLUSIONS .................................................................................................. 154
Introduction too Discussion and Conclusion Section ..................................... 154
Conclusion and Recommendation .................................................................. 156
Statistical Conclusions on the Cognitive Rehabilitation of Memory
Deﬁcits in Individuals with TBI ..................................................................... 156
Descriptive Conclusions on the Cognitive Rehabilitation of Memory
Deﬁcits Study Characteristics ......................................................................... 160
Descriptive Conclusions on the Cognitive Rehabilitation of Memory
Deﬁcits Participant Characteristics ................................................................. 161
Statistical Conclusions on the Cognitive Rehabilitation of Attention
Deﬁcits in Individuals with TBI ..................................................................... 162
Descriptive Conclusions on the Cognitive Rehabilitation of Attention
Deﬁcits Study Characteristics ......................................................................... 167
Descriptive Conclusions on the Cognitive Rehabilitation of Attention
Deﬁcits Participants Characteristics ............................................................... 168
Statistical Conclusions on the Cognitive Rehabilitation of
Socio—behavioral Deﬁcits in Individuals with TBI ......................................... 169

vii

Descriptive Conclusions on the Cognitive Rehabilitation of

Socio-behavioral Deﬁcits Study Characteristics ............................................ 171

Descriptive Conclusions on the Cognitive Rehabilitation of

Socio-behavioral Deﬁcits Study Characteristics ............................................ 172

Summary of Meta Analysis Study .................................................................. 175

Summary of Cognitive Rehabilitation with Individuals with Memory,

Attention and Socio-behavioral Deﬁcits following TBI ................................. 177

Methodological Issues ............................................................................... 178

Future Research on Cognitive Rehabilitation with Individuals with

Memory, Attention, and Socio-behavioral Deﬁcits Following TBI ............... 180
APPENDICES ..................................................................................................... 185
Appendix A

The Coding Instrument ................................................................................... 186
Appendix B

Operational Deﬁnitions for the Article Review Sheet....................................188
Appendix C

List of 120 Studies used in the Data Analysis and Synthesis of Cognitive

Rehabilitation of Memory Deﬁcits in Individuals with TBI .......................... 191
Appendix D

List of 67 Studies used in the Data Analysis and Synthesis of Cognitive

Rehabilitation of Attention Deﬁcits in Individuals with TBI ......................... 198
Appendix E

List of 30 Studies used in the Data Analysis and Synthesis of Cognitive

Rehabilitation of Socio-behavioral Deﬁcits in Individuals with TBI ............. 202
Appendix F

List of Studies Reviewed but were not used in the Data Analysis and

Synthesis ......................................................................................................... 205
REFERENCES .................................................................................................... 225

viii

LIST OF TABLES

Table Page
1. Cognitive Rehabilitation of Memory Deficits in Individuals with TBI

Sources of Publication .................................................................................. 114
2. Cognitive Rehabilitation of Memory Deficits in Individuals with TBI

Studies Per Year from 1980 to 1990 .............................................................. 115

3. Cognitive Rehabilitation of Memory Deficits in Individuals with TBI
Studies Per Year from 1991 to 2003 .............................................................. 115

4. Cognitive Rehabilitation of Memory Deﬁcits in Individuals with TBI
Demographic Data on Subjects ...................................................................... 117

5. Cognitive Rehabilitation of Memory deﬁcits Severity of TBI Subjects ....... 117

6. Statistical Results on the Cognitive Remediation of Memory Deﬁcits
following TBI ................................................................................................. 119
7. Effect Size Scores by Category, Number, and Percent of the Total .............. 120
8. Cognitive Remediation of Memory Deﬁcits after TBI Type of Score
Categories ...................................................................................................... 121
9. The Fourteen most Extreme ES Scores, Absolute Scores and Score Type ...124

10. Cognitive Remediation of Memory Deﬁcits following TBI with

Fourteen Outlying Scores Removed .............................................................. 125
11. Comparison of Total Scores and Adjusted Scores ......................................... 125
12. Severity of Injury on Total Score Set ............................................................ 126
13. Severity of Injury on Adjusted Score Set ...................................................... 126

14. Cognitive Rehabilitation of Attention Deﬁcits in Individuals with
TBI Sources of Publication ............................................................................ 129

15. Cognitive Rehabilitation of Attention Deficits in Individuals with TBI
Studies Per Year from 1980 to 1990 .............................................................. 130

16. Cognitive Rehabilitation of Attention Deﬁcits in Individuals with TBI
Studies Per Year from 1991 to 2003 .............................................................. 130

ix

17.

18.

19.

20.

21.

22.

23.

24.

25.

26.

27.

28.

29.

30.

31.

32.

33.

Cognitive Rehabilitation of Attention Deﬁcits Demographic Data
on Subjects ..................................................................................................... 132

Cognitive Rehabilitation of Attention Deﬁcits in Individuals with TBI
Cultural/Racial Makeup of TBI Subjects ....................................................... 132

Cognitive Rehabilitation of Attention Deﬁcits Severity of TBI Subjects ..... 132

Statistical Results on the Cognitive Remediation of Attention Deficits

Following TBI ................................................................................................ 134
Effect Size Scores by Category, Number, and Percent of the Total .............. 137
Cognitive Remediation of Attention Deﬁcits on Individuals with TBI

Type of Score Categories ............................................................................... 137
The Eight most Extreme ES Scores for Cognitive Rehabilitation of

Attention Deﬁcits following TBI ................................................................... 138
Cognitive Remediation of Attention Deficits following TBI with Eight
Outlying Scores Removed ............................................................................. 138
Comparison of Total Scores and Adjusted Scores for Cognitive

Rehabilitation of Attention Deficits following TBI ....................................... 139
Severity of Injury on Total Score Set ............................................................ 139
Severity of Injury on Adjusted Score Set ...................................................... 140

Cognitive Rehabilitation of Socio-behavioral Deﬁcits in Individuals
with TBI Sources of Publication .................................................................... 143

Cognitive Rehabilitation of Socio-behavioral Deficits in Individuals with
TBI Studies Per Year from 1980 to 1990 ...................................................... 143

Cognitive Rehabilitation of Socio-behavioral Deﬁcits in Individuals
with TBI Studies Per Year from 1991 to 2003 .............................................. 144

Cognitive Rehabilitation of Socio-behavioral Deﬁcits of Individuals
with TBI Demographic Data on Participants ................................................. 146

Cognitive Rehabilitation of Socio-behavioral Deﬁcits of Individuals
with TBI Participants ..................................................................................... 145

Statistical Results on the Cognitive Remediation of Socio-behavioral
Deﬁcits following TBI ................................................................................... 147

34.

35.

36.

37.

38.

39.

40.

Effect Size Scores by Category, Number, and Percent of the Total .............. 150

Cognitive Rehabilitation of Socio-behavioral Deﬁcits on Individuals with

TBI Type of Score Categories ........................................................................ 150
The Five most Extreme ES Scores for Cognitive Rehabilitation of
Socio-behavioral Deficits following TBI ....................................................... 151
Cognitive Remediation of Socio-behavioral Deficits following Five
Outlying Scores Removed ............................................................................. 151
Comparison of Total Scores and adjusted Scores for Cognitive
Rehabilitation of Socio-behavioral Deﬁcits following TBI ........................... 152
Severity of Injury on Total Score ................................................................... 152

Severity of Injury on Adjusted Score Set ....................................................... 153

xi

CHAPTER I
INTRODUCTION
Epidemiology

Traumatic brain injury is a term that describes a variety of conditions involving
external insults to the head culminating in brain damage. Head injury, head trauma and
brain injury all refer to conditions of traumatic brain injury (TBI) and may be used
interchangeably throughout this paper. Traumatic brain injuries can be classiﬁed as
either open or closed head injuries. Open head injuries occur when an external object
penetrates the skull. In contrast, closed head injuries result from a rapid acceleration of a
stationary or slower moving head by a moving object (acceleration injuries) or by a
deceleration of the head as it comes in contact with a stationary or slower moving object
(deceleration injuries) (Levin, Benton & Grossman, 1982).

Traumatic brain injury is a major health issue in the United States, and other
countries where vehicular accidents, sporting accidents, falls and interpersonal violence
are common occurrences (Jennett & Teasdale, 1981). The incidence of traumatic brain
injury (TBI) has reached epidemic proportions in the past two decades. Coupled with
this increased incidence is the notable rise in the number of survivors of moderate and
severe traumatic brain injuries sustained in motor vehicle and other accidents, which
according to Wehman and Goodall (1990), is a result of advances in neurosurgery,
emergency evacuation procedures, rehabilitation techniques, and psychopharrnacology.

This is important, because up to twenty years ago, many people who sustained a
TBI did not survive (Misenti, Lucas, & Thompson, 1992). The past decade has seen a

major emphasis placed on the rehabilitation and treatment of individuals who have

acquired a traumatic brain injury. Unfortunately, most of these individuals are
sufﬁciently compromised to require specialized services if they are to return to the
workforce (Wehman & Goodall, 1990).

Epidemiological data on TBI has been difficult to obtain since head injury is
generally not recorded as a single medical diagnosis by hospitals (Morse & Montgomery,
1992). Additional data collection concerns include omissions for mild TBI and death
prior to arrival at the hospital (Grimm & Bleiberg, 1986). Definition differences for TBI
are also attributed to some head injuries being excluded (Frankowski, 1986). The
National Center for Health Statistics (1984) excluded skull fracture-related deaths from
their reporting. On the other hand, Klauber and others (1978) included skull fractures in
their reporting of fatal head injuries, but excluded TBI-related gunshot wounds.
Frankowski and others (1981) included all skull fractures and intracranial injuries that
resulted in death, even from suicide. In order to address this methodological problem, the
Center for Disease Control and Prevention established Guidelines for Surveillance of
Central Nervous System Injury (Thurman et al., 1999). The standard TBI case deﬁnition
identifies the occurrence of a head injury, caused by a blunt or penetrating trauma or from
acceleration-deceleration forces, resulting in diminished consciousness, amnesia, other
neurological or neuropsychological abnormalities, skull fracture, diagnosed intracranial
lesions, or death.

According to Jennett and MacMillan (1981), it is difficult to determine how often
head injuries occur, because many are not serious enough to warrant admission to
hospital, and statistics about emergency room attendees are unreliable and incomplete.

However, a number of studies have demonstrated that traumatic brain injury is a common

occurrence in the United States. Frankowski (1986) and Jennett (1983) estimated that
approximately 7 million head injuries occur annually in the United States, with about
500,000 hospital admissions. The National Head Injury Foundation (1984) estimated that
approximately 500,000 to 750,000 persons annually in the United States survive a brain
injury. More recent estimates put the number at approximately 700,000 people acquiring
a head injury every year in the United States (Roessler, Schriner and Price, 1992). Based
on these numbers, McMordie, Barker and Paolo (1990) concluded that the incidence rate
for traumatic brain injury is higher than that for epilepsy, Parkinson’s disease, multiple
sclerosis, Huntington disease, and amyotrophic lateral sclerosis combined.

Epiderniologically, the incidence of traumatic brain injury peaks in two age
groups, fifteen to twenty—four years of age, and seventy years old and higher. The
primary cause of traumatic brain injury in the eighteen to thirty year old age groups is
motor vehicle accidents, while falls are the primary cause of traumatic brain injury in
older individuals. Thus, the mechanism of injury differs for these two groups, resulting
in different neuropathological features and neurobehavioral proﬁles. The causes of
traumatic brain injury in children are largely dependent upon age. For example, in
infants the primary cause of TBI is child abuse; in young children, falling is the primary
cause; in older children, pedestrian and car accidents; and in adolescents and younger
adults, motor vehicle accidents, usually with alcohol involvement is the primary cause
(Routh, 1987).

Traumatic brain injury is the leading cause of death among the young and the
most frequent cause of brain damage for those under 40. As Rimel and Jane (1983)

stated, "more persons die on American highways each year in automobile accidents than

were lost in the entire Vietnam conﬂict, and central nervous system trauma is the single
most common cause of death in these accidents (p. 9). Additionally, there is an age-
associated increase in mortality rates of persons experiencing traumatic brain injury
regardless of severity of injury, with approximately a twenty- percent mortality rate at
age eighty. The risk of death increases in the older age group when other coexisting
medical problems are prevalent. Studies have shown that persons age ﬁfty to seventy-
five at the time of injury revealed a high incidence of generalized deterioration and
dementia, regardless of the severity of injury. A review of studies on the impact of
traumatic brain injury (Goldstein & Levin, 1995) revealed that traumatic brain injury is
more disruptive in terms of mortality and capacity to resume independent functioning
within this age group.

Each year over one million individuals under the age of nineteen acquire
neurological damage resulting in some form of hospital treatment. Approximately
150,000 of these individuals remain hospitalized and over 20,000. sustain a moderate or
severe head injury (Goldstein & Levin, 1995). Most of these injuries are the result of
motor vehicle accidents, falls, sports injuries, and bicycle accidents. In adults, motor
vehicle accidents, violent crime, unsuccessful suicide attempts, falls, and stroke are the
most common contributors of TBI.

A person who has acquired a head injury is three times more likely to acquire a
second head injury and among those who have had multiple head injuries, the incidence
of a subsequent head injury is eight times that of the general population (Rimel & Jane,

1983). However, despite the onset of traumatic brain injury, the life expectancy for

survivors is 40 years from the time of injury, which according to Rimel and Jane (1983)
is close to a normal life expectancy.

Recent studies suggest that 1.5 million Americans, or 200 per 100,000 sustain a
TBI annually (Brooks, Gabella, Hoffman, Sosin, & Whiteneck, 1997). Approximately
230,000 are hospitalized for their injuries and roughly 50,000 die as a result of their TBI
related injuries. Brooks et a1. (1996) estimate that nearly 80,500 or 35% of the 230,000
individuals hospitalized will experience signiﬁcant long-term disability related to their
head injury. McAllister (1997) stated that the increased number of individuals surviving
TBI will be challenged by signiﬁcant cognitive and emotional changes. It is estimated
that an additional 1 million individuals who sustain a TBI and are not hospitalized will
experience chronic disabilities associated with their head injury (Thurman et al., 1999).
Sequelae of Traumatic Brain Injury

Survivors of head injury sustain any number of medical, physical, cognitive,
psychosocial, and behavioral problems resulting from their injury, which presents a
challenge for health professionals. Because of the sequelae of traumatic brain injury, the
National Head Injury Foundation has referred to head injury as the "silent epidemic,
which depicts the severe nature of this problem, yet the potential for oversight and mis-
diagnosis.

Persons with traumatic brain injuries can encounter a wide variety of physical,
cognitive and behavioral deficits. Physical factors may include chronic fatigue, impaired
balance and coordination, seizure activity, chronic pain, impaired motor skills, and visual
difficulties. Individuals may also experience chronic, debilitating head and neck/back

pain, which can have signiﬁcant impact on vocational potential (Hurt, 1991). As such,

the person's ability to work an 8-hour day is compromised, often resulting in a three to
four hours workday.

According to Rosenthal (1983), behavioral problems associated with traumatic
brain injuries are common, and represent a major problem in rehabilitation efforts
designed to help persons resume productive, domestic or community roles. Furthermore,
Brooks (1985) stated that behavioral problems represent the most frequent source for the
family's perception of traumatic brain injuries as a persisting burden. Persons with
traumatic brain injury may experience a range of behavior disorders, including, but not
limited to, restlessness, agitation, combativeness, emotional liability, confusion,
hallucinations, and other disturbed perceptions, disorientation, depression, paranoid
ideation, hypomania, and confabulation (Garoutte & Aird, 1985; Kueatus, Harot, Peck &
Kornstein, 1985). With such behavioral deﬁcits, persons with traumatic brain injuries
become aware of their limitations, and they become discouraged, demoralized, or even
hopeless (Fisher, 1985). Rosenthal (1983) stated that persons with traumatic brain
injuries are less able to perform physically, become more dependent socially, and often
feel a sense of impotence in trying to rebuild their lives. Consequently, social
relationships are less rewarding and often diminished, vocational prospects are altered,
and life is perceived as less interesting.

In many cases, work and educational difﬁculties are a result of the altered
cognitive status following traumatic brain injury (Lain, Priddy, & Johnson, 1991).
Cognitive impairments may result in a variety of difﬁculties both on and off the job or at
school. For example, memory impairments can affect an individual's ability to learn new

information and remember job tasks. Attention/concentration problems may result in

difﬁculty staying on task due to distractibility; problems paying attention to many tasks
or aspects of a task simultaneously; and difﬁculty returning to task after an interruption.
Visual processing impairments may result in the misinterpretation of visual information,
and auditory processing impairments can result in difficulties comprehending verbal
instructions resulting in a need for repeated instructions. The ability to organize, plan,
goal set and monitor behavior may be diminished, resulting in the person becoming easily
overwhelmed by complex or non- repetitive tasks. Likewise, impaired reasoning skills
may affect the individual's ability to grasp abstract concepts and apply these to speciﬁc
tasks. Low frustration tolerance may result in irritability, impatience, and angry outbursts
aimed at supervisors, teachers and/or co-workers, whereas, lack of initiation may result in
a need for more supervision and directives from others within the environment (Hurt,
1991).
Threats to Employment

Impairment resulting from traumatic brain injury often threatens the ability for an
individual to return to gainful employment. As previously mentioned, cognitive,
psychosocial, and behavioral deficits often serve as obstacles towards a return to
employment. The ability to work is one of the most signiﬁcant attributes in our society.
Moos (1986) acknowledged that the meaning of work is prominent to many individuals
(cited in Szymanski & Parker, 1996). Work deﬁnes an individual's worth and place
within society. In addition, work provides numerous ﬁnancial as well as psychological
and social beneﬁts. Our society places a heavy emphasis on individuality and
independence. As such, in order to afford commodities such as food, shelter, clothing,

and other necessary products, it is essential to have some type of employment.

The inability to work following TBI often serves to exacerbate problems in
psychosocial functioning and family adjustment. As a result of unemployment, Oddy,
Coughlan, Tyerrnan and Jenkins (1985) stated that persons with head injuries often
experienced increased difﬁculties in social functioning such as social isolation, decreased
self-worth and despair. Bond (1976) found that work and leisure activities were the most
disrupted aspects of daily life following severe head injury.

Work also influences a person's psychological identity, aspects of well being, and
brings social stability to an individual's life. Work provides the individual the ability to
structure his/her time, which was felt by Beme (1961) to be crucial for adaptive
functioning. Freud in his writings, identiﬁed the most signiﬁcant indication of
psychological stability is the individual ability to love and to work effectively (Erickson,
1950). It is true that some form of employment sets one's place within the community of
human kind (Szymanski & Parker, 1996). Among the many beneﬁts experienced through
gainful employment is the opportunity to develop a social network. Persons with severe
head injuries often cite lack of social contact which is attributed to diminished
opportunities to make friends since very little time is spent in the community as the most
frequently mentioned problem (T homsen, 1974). Lishman (1978) stated that those who
suffer head trauma encounter difficulties in vocational, personal and social adjustment.
Oddy et a1. (1985) in a study of head injured patients found that, ". . .those who were
working had been able to rebuild their social lives and sometimes marry" (p. 567).
Statement of the Problem

After examining the impact of traumatic brain injury, several issues become

apparent. The fact that this condition occurs at epidemic rates with estimates as high as 7

million injuries occurring annually, with approximately 500,000 persons being admitted
to hospital emphasizes the catastrophic extent of the problem (Frankowski, 1986; Jennet,
1983). As previously mentioned, traumatic brain injury occurs most often among
individuals under age 30 with 72 percent of all injuries occurring within this age group
(Rimel & Jane, 1983). The effects of traumatic brain injury, whether mild, moderate or
severe, have a deleterious effect upon an individual’s overall level of functioning and
subsequent life goals. Following a TBI the brain undergoes a process of natural healing
called spontaneous recovery. Usually, this process occurs during the ﬁrst six months
after the injury, however, it may continue for many years (Butler & N amerow, 1988;
Oddy, Bonham, McMillan, & Stroud, 1988). However, there is no way of predicting
when and in what areas of the brain spontaneous recovery will occur and what deﬁcit
areas will be affected. In order to address the deﬁcits that remain following a period of
spontaneous recovery, psychologists, speech pathologists, educators, and others in the
ﬁeld of rehabilitation have recognized the residual effects of traumatic brain injury and
have developed methods for cognitive rehabilitation.

Many studies have examined variables associated with cognitive rehabilitation
and its effects on the remediation of attention (Benedict, 1989; Ben-Yishay, Piasetsky, &
Rattock, 1987; Malec, 1984), memory (Glasgow, Zeiss, Barrera, Lewinsohn, 1977;
Wilson, 1987; Boring, 1988) and self-regulation (Webster & Scott, 1983; Lira, Came, &
Masri, 1983; Cicerone & Wood, 1987) following traumatic brain injury. Despite this, a
severe disparity exists in the literature regarding the effectiveness of cognitive
rehabilitation interventions on subsequent vocational outcomes. This is particularly

problematic given that research shows that successful outcomes and increased quality of

life of persons with traumatic brain injury are associated with increases in attention and
memory and reduced social-behavioral deﬁcits.

Research that explores the relationship between cognitive rehabilitation
interventions and subsequent outcomes following traumatic brain injury increases our
understanding of the impact traumatic brain injury has on subsequent quality of life.
Increased knowledge of these relationships can lead to future development of innovative
methods for counseling and rehabilitation. Additionally, such research will assist
psychologists, counselors and other rehabilitation professionals in the development of
innovative counseling and treatment strategies.

The purpose of this study is to assess the effectiveness of cognitive rehabilitation
interventions on subsequent outcomes of persons with traumatic brain injuries.
Speciﬁcally, the study will explore the effectiveness of cognitive rehabilitation
interventions on the remediation of memory, attention and socio-behavioral/self—
regulation following TBI. In addition, characteristics associated with traumatic brain
injury will be analyzed with regard to their inﬂuence upon subsequent outcomes
following cognitive rehabilitation interventions. These characteristics include premorbid
factors such as: (1) age at time of accident, (2) years of education, and (3) type and level
of employment. Additionally, factors related to severity of injury and duration of
rehabilitation on subsequent outcomes following cognitive rehabilitation intervention
with persons with traumatic brain injury will be explored.

Considerable research attention has been focused during the past two decades on
cognitive rehabilitation with persons with traumatic brain injury. The problem is that the

accumulated information from this research does not appear to be clear and consistent in

10

regards to the impact of cognitive rehabilitation on the remediation of memory and
attention deficits following traumatic brain injury. It is imperative that these ﬁndings be
synthesized into a meaningful whole. As such, a methodologically rigorous, large scale
integration of the numerous research ﬁndings is warranted.
Purpose of the study
The purpose of this study is to assess the effectiveness of cognitive rehabilitation
interventions on subsequent outcomes of persons with TBI. Speciﬁcally, the study will
explore the effectiveness of cognitive rehabilitation interventions on the remediation of
memory, attention, and socio-behavioral deﬁcits following TBI using a combination of
meta-analytic procedures and descriptive statistics. Memory, attention, and socio-
behavioral deﬁcits have been linked to poor vocational outcomes and quality of life for
individuals with traumatic brain injury.
Major research question(s) and Hypothesis
The principal research questions are:
(1) How effective is cognitive rehabilitation intervention on the remediation
of memory deﬁcits following traumatic brain injury?
(2) How effective is cognitive rehabilitation intervention on the remediation
of attention deficits following traumatic brain injury?
(3) How effective is cognitive rehabilitation intervention on the remediation
of socio-behavioral deﬁcits following traumatic brain injury?
(4) What are the relationships between factors such as age at time of accident,

years of education, socio economic status, severity of injury, and ethnic

ll

background of individuals on subsequent outcomes following cognitive
rehabilitation intervention with persons with traumatic brain injury?

Hypotheses:

Within this investigation, the following hypotheses were tested:
Hypothesis 1:

Cognitive rehabilitation intervention will be positively correlated with the

remediation of memory deficits following traumatic brain injury.
Hypothesis 2:

Cognitive rehabilitation intervention will be positively correlated with the

remediation of attention deﬁcits following traumatic brain injury.
Hypothesis 3:

Cognitive rehabilitation intervention will be positively correlated with

remediation of socio-behavioral deﬁcits following traumatic brain injury.

Significance of the Study

A number of issues or factors are apparent after examining the literature
associated with traumatic brain injury. Following traumatic brain injury, a person's
vocational functioning is often threatened. This is due to physical, cognitive, psycho-
social, and behavioral deﬁcits, which often impede a return to employment. Societal
demands for educational achievement and vocational productivity cannot be
underestimated; therefore, the person with traumatic brain injury must function
adequately in these two areas in order to live independently. The beneﬁts of work are
numerous; for example, a sense of self worth and esteem are inﬂuenced by an

individual’s ability to feel productive and as a contributing member of society. The

12

social and personal consequences of the individual's inability to work contribute directly
to deterioration in the quality of life (Klonoff, Snow, & Costa, 1986; McMordie &
Barker, 1988). Return to work is essential for structure, social and psychological
functioning as well as ﬁnancial gains as such it merits special attention.

According to Jennett and Teasdale (1981), traumatic brain injury constitutes a
major problem in the health care delivery system. Traumatic brain injury continues to
occur at an alarming rate with annual estimates exceeding 500,000 injuries, severe
enough to require hospitalization. Additionally, 72 percent of all injuries occur to
individuals under the age of 30 (Rimel & Jane, 1983). Males comprise two-thirds of
persons with traumatic brain injury. It is estimated that 50,000 people are permanently
disabled annually as a result of traumatic brain injury (National Head Injury Foundation,
1984); and result in direct and indirect costs of approximately 4 billion dollars annually
(Kalsbeek, McLaurin, Harris & Miller, 1980).

Lishman (197 8) noted that, among the majority of individuals who survive
moderate and severe head injuries, the long term mental (cognitive, behavioral, and
emotional) sequelae greatly exceed the physical sequelae as the primary causes for the
difﬁculties encountered by these individuals in their later vocational, personal, and social
adjustment.

There is general agreement in the literature that traumatic brain injury results in
devastating consequences. Less than three percent of persons with head injuries treated in
rehabilitation programs were able to maintain employment for more than one year (Ben-
Yishay, Silver, Piatsesky, & Rattok, 1987). Additionally, unemployment among this

population is partly a consequence of diverse personality, behavioral and cognitive

13

 

changes arising from pathophysiological alternations in the brain following injury
(Burke, Wesolowski, & Guth, 1988).

A study of the relationship of cognitive rehabilitation intervention on
outcomes following traumatic brain injury may enable psychologists, counselors, and
rehabilitation practitioners to develop intervention strategies aimed at improving
vocational outcomes. As a statistical integration of research studies that examined
cognitive rehabilitation intervention on outcomes following TBI, this study will provide a
verifiable knowledge base of cognitive rehabilitation as an intervention strategy. It
should serve to ensure an accurate representation of the variables associated with
cognitive rehabilitation as an intervention strategy with persons with TBI, and should
minimize duplication of research efforts. The ﬁndings of the meta-analytic review
should be useful in both theory-building and practical applications such as program
development and training. Moreover, it should identify previously unexplored variables
and direct further research in cognitive rehabilitation interventions following traumatic
brain injury. From a clinical perspective, this study will help practitioners’ select
appropriate goals, objectives and activities for individual clients. Also, from an
educational standpoint, this study may help to foster cuniculum development and
intervention strategies as it relates to age, education and certain factors on vocational
adjustment. As stated by Wehman and Kreutzer (1991) a better understanding of the
return to work process must inevitably have an impact on rehabilitation.

Definition of Terms
In this section of the proposal, certain terms that are important to this

investigation on the effectiveness of cognitive rehabilitation strategies on vocational

14

outcomes must be deﬁned in order to maintain clarity in describing certain phenomena
related to cognitive rehabilitation and traumatic brain injury. Because of the nature and
sequelae of traumatic brain injury as well as the complex nature of cognitive
rehabilitation a broad array of concepts, words, and terms needs to be deﬁned.

Traumatic brain iniury consists of a variety of conditions involving external
insults to the head culminating in brain damage. The terms brain injury, head injury and
head trauma all refer to conditions of traumatic brain injury.

@en head iniury are those that result when the scalp and/or skull is penetrated by
an external object, such as a gunshot wound.

Closed head injury is as a result of direct contact forces and inertial forces. What
happens in this case is as the brain surfaces are pushed against the inner surface of the
skull upon sudden acceleration or deceleration, the brain sustains bruising (Levin,
Benton, & Grossman, 1982).

Severity of iniury it has been argued that the longer the period of loss of
consciousness, the less successful are the vocational outcomes (Cartlidge, 1981; Plum &
Levy, 197 8). As such, it is important to investigate what effects the severity of injury has
on vocational outcomes. The following categories of severity are:

1. Level I (Loss Of Consciousness (L.O.C.) of 24 - 72 hours).

2. Level II (L.O.C. of 4 - 7 days).

3. Level III (L.O.C. of 8 - 15 days).

4. Level IV (L.O.C. of 16 - 30 days).

5. Level V (L.O.C. of 30 days or more).

15

 

Another deﬁnition is related to the term vocational outcomes. To obtain a clear
and accurate assessment of vocational outcomes following traumatic brain injury, the
following categories are offered:

1. Full-Time Employment

Professional, managerial, technical
Clerical

Service

Structural

1) Skilled

2) Unskilled

9.09"!”

2. Part-Time Employment

3. Supportive Employment/Sheltered Employment

4. College

Cognitive rehabilitation is a systematic, functionally oriented service of
intervention that is based on assessment and understanding of the client’s brain-
behavioral deﬁcits. Speciﬁc interventions may have various approaches, including (1)
reinforcing, strengthening, or reestablishing previously learned patterns of behavior; (2)
establishing new patterns of cognitive activity through compensatory cognitive
mechanisms for impaired neurologic systems; (3) establishing new patterns of activity
through external compensatory mechanisms such as personal orthoses or environmental
structuring and support; and (4) enabling persons to adapt to their cognitive disability,
even though it may not be possible to directly modify or compensate for cognitive
impairments, in order to improve their overall level of functioning and quality of life
(Cicerone, et al., 2000)

Meta-aaalysis is "the statistical analysis of a large collection of analysis results

from individual studies for the purpose of integrating the ﬁndings (Glass, 1976, p. 3).

l6

Effect size is a quantitative measure of the results of an individual study (Glass,
1976). However, if most of the studies are correlational, the product-moment correlation
coefficient (or a statistic that is convertible to a product-moment correlation coefficient)
should serve as the effect size (Glass, McGaw, and Smith, 1981).

Methodological characteristics refer to the general features of the studies (e.g.,
sample size, date of publication, or the type of analysis) (Glass et al., 1981).

Substantive characteristics refer to features of the studies that are related to the
problem studied (e.g., sex, age, educational status, or ethnicity) (Glass et al., 1981).

Rationale of Meta Analysis as the Statistical Procedure

Research utilizing single experiments as well as studies in the behavioral sciences
rarely provides deﬁnitive answers to research questions. Rather, if progress is to be made
in the social and behavioral sciences, it must be through the discovery of underlying
trends and principles developed from the accumulation and reﬁnement of a large body of
studies (Wolf, 1986). Thus the integration of empirical research through literature
reviews helps to clarify the state of science at a given point. Meta-analysis can be viewed
as a synthesis of research. It can distinguish coding reliability, validity of studies
analyzed, allows for clearer conclusions about the relationship between specific
independent and dependent variables, and provides the technique for summing up a large
body of separate but similar experiments (Swanson, 1996). According to Wolf (1986),
"meta-analysis is the application of statistical procedures of the collections of empirical
ﬁndings from individual studies for the purpose of integrating, synthesizing, and making

sense of them" (p. 5). Castro and Mastropieri (1986) state that, "it is a method, it is not a

17

panacea, but it will often be quite valuable when applied and interpreted with care" (p.

417).

18

CHAPTER II
REVIEW OF THE LITERATURE

The purpose of this research is to determine the effectiveness of cognitive
rehabilitation interventions on subsequent outcomes of persons with traumatic brain
injury. Speciﬁcally, the study will explore the effectiveness of cognitive rehabilitation
interventions on the remediation of memory, attention, and socio-behavioral deﬁcits
following TBI using a combination of meta-analytic procedures and descriptive statistics.
The aim is to assimilate and synthesize the literature regarding the impact of cognitive
rehabilitation on subsequent outcomes. Relevant articles in this literature will be
organized and reviewed as follows: (a) sequelae of traumatic brain injury, (b)
rehabilitation of attention deficits, (c) rehabilitation of memory deﬁcits, (d) rehabilitation
of socio-behavioral deficits, (e) vocational outcome studies, (f), cognitive rehabilitation
and (g) meta-analysis.

Overview of Traumatic Brain Injury

Historical data and current trends suggest that TBI is a leading cause of death
among young Americans (Thurman et al., 1999). This was found to be true in those
individuals under age 38 (Rimel, Jane & Bond, 1990). National data ﬁrst became
available for TBI-related deaths in 1978 (National Center for Health Statistics, 1984).
Data for all reported brain injury deaths in 1978 found that 24% were attributed to an
intracranial injury. Klauber, Barrett-Connor, Marshall and Bowers (1978) found rates of
TBI-related deaths in 1978 estimated at 22.3 per 100,000 in San Diego County.
Frankowski, Klauber, and Tabaddor (1981) conducted a collaborative study in 1981,

inclusive of three counties located in New York, Texas, and California and found

19

incidents of TBI-related mortality to range from 27 to 32 per 100,000. Another study
compared TBI mortality rates for inner city Chicago and a neighboring suburb and found
rates of 32 and 13 respectively per 100,000. More recently, the National center for
Health Statistics (1994) reported that for the periods of 1980 through 1994, TBI related
deaths decreased from 24.7 per 100,000 to 19.8 per 100,000. In another study, the Center
for Disease Control and Prevention (1998) found slightly higher rates with 22.6% of
32,112 reported TBI cases resulting in death.

Incidence of TBI-related deaths has found differences among gender and age
groups. TBI fatalities for males are 30.7 per 100,000 and 9.3 per 100,000 for females
(National Center for Health Statistics, 1994). Increased rates of TBI fatalities are found
with both sexes for ages 15-24 and over 70 years of age (National Center for Health
Statistics, 1984). Mortality associated with TBI is similar among males and females until
the age of 15 when males become at least three times more likely to experience a fatal
TBI (Annegers, Grabow, Kuland, & Laws, 1980; Thurman et a1, 1990). Although TBI-
related fatalities experience a peak for males between the ages of 15-24, the highest peak
of TBI mortality rates are for males 75 years and older at 46.3 per 100,000 (Thurman et
al., 1999).

There are variations in study findings pertaining to the etiology of TBI-related
deaths. The Center for Disease Control and Prevention ( 1998) found 49% of TBI
fatalities attributed to transportation accidents (motor vehicles, bicycles, pedestrian, and
recreational vehicles), 26% to falls, 10% to ﬁrearms, and 8% to assault without a ﬁrearm.
In a separate study the Center for Disease Control and Prevention (1997) found gunshot

injuries were the leading cause of fatalities among males 15 to 84 years of age. Whitman

20

(1984) as well as other researchers found inner cities had more than 50% of TBI fatalities
associated with ﬁrearms and suburban areas accounted for 50% of TBI deaths being
related to transportation related injuries. Among females, transportation related injuries
are the leading cause of TBI deaths for females from birth to 74 years of age, with peaks
between the ages of 15 to 24. TBI associated female deaths attributed to ﬁrearms and
transportation accidents were nearly identical for the 30 to 54 age groups and for females
75 and older, the majority was related to falls (Center for Disease Control and Prevention,
1997).

Racial and ethnic differences have existed historically for TBI-related deaths.
Cooper, Tabaddor and Hauser (1983) found that TBI fatalities among African Americans
and Hispanics were higher than White Americans by ratios of 1.8 and 1.5 respectively.
The National Center for Health Statistics (1994) reported that deaths resulting from TBI
are highest among African Americans (25.5 per 100,000), followed by White Americans
(19 per 100,000) and for all other racial groups combined (15.3 per 100,000). Increased
rates of TBI deaths among minority groups are attributed to greater incidents of
interpersonal violence, particularly in urban areas (Cooper et al., 1983; Whitman et al.
1984). TBI deaths by gunshot attributed for 13.6 per 100,000 among African Americans,
which is the leading cause of deaths for this group, compared to 7.9 per 100,000 for
White Americans (National Center for Health Statistics, 1994).

Recovery after Traumatic Brain Injury

Recovery after traumatic brain injury is not a speedy process like most other

medical injuries. Individuals with TBI usually take several years to regain many of the

cognitive and psycho-social abilities that may have been altered because of the injury.

21

Some of the notable changes that can be observed include those of a physical and
cognitive nature, whereas changes in emotional and interpersonal abilities, which make
up the essence of a person, are usually more subtle. Improvements in cognitive and
psychosocial abilities are critical if individuals with traumatic brain injury are to recover
to the fullest extent possible and regain some or all of their pre-injury abilities. Thus,
rehabilitation efforts are viewed as efforts that promote, not cause, recovery.

Maximal recovery from neurological impairment following traumatic brain injury
in terms of clinical estimation of duration of recovery remains a controversial issue
(Hanlon, Dobkin, Hadler, Ramirez, & Cheska, 1992). A number of studies support the
conclusion that the most rapid period of recovery occurs during the ﬁrst six months post-
injury; however, recovery continues on a slow and steady course, reaching a maximum at
approximately twenty-four months post-injury (Hanlon et al., 1992; Kertesz, 1985;
Prigatano, 1987). Research on IQ values post-injury lends support to the ﬁrst six months
being the most rapid recovery period. A study conducted by Bond in 1975 (cited in
Prigatano, 1987) showed that Verbal IQ showed the most rapid improvement over the
first six months post-injury. Performance IQ scores recovered more slowly with the most
substantial improvements occurring up to one year post-injury. Continued improvements
based on IQ results are not uncommon up to two years post-injury and even after two
years, though these improvements are rarely dramatic (Hanlon et al., 1992).

A number of problems exist in the studies that examined the issue of recovery of
individuals with traumatic brain injury post-injury. There is the problem of degree of
variability in the type and severity of brain pathology associated with traumatic brain

injury. Additionally, there is signiﬁcant variability in the individuals' characteristics prior

22

to the injury including intelligence, memory, and personality characteristics, all of which
inﬂuence recovery. Overall, three factors have been found to contribute to the level and
course of recovery. These factors according to Prigatano (1987) include the individual's
abilities and characteristics pre-injury, the type and severity of the injury, and the effort
put forth toward recovery post-injury.

In addition, research in the area of recovery has shown that within the area of
higher cognitive functioning, such as memory, different aspects or components may
improve over time while others may not. Different patterns in the rate and level of
recovery in each area of higher cognitive functioning may occur. Improvements in
certain areas have been documented several years post-injury, particularly among
individuals who were adolescents or young adults at the time of injury. Also there is
strong evidence that psychosocial functioning post-injury may contribute significantly to
the recovery of cognitive functioning. Prigatano (1987) stated that results from most
studies on recovery suggest that individuals improve after TBI, however, the course is
variable and some individuals even show deterioration of some abilities over time.

Research has documented that some individuals with TBI make substantial
progress post-injury such that cognitive rehabilitation and educational activities are
believed to facilitate the rate and/or level of recovery. Additionally, intensive
neuropsychological based rehabilitation has been shown to signiﬁcantly increase the level
of psychosocial adjustment in individuals who are relatively self-sufﬁcient in terms of
activities of daily living (Prigatano, 1987). Overall, results from these studies suggest

that the brain has the ability to learn and re-adapt. However, Prigatano (1987) stated that

23

the degree of recovery can be described as "a clinical and scientific guessing game (p.
605).

The passage of time is a significant factor in the recovery of persons who sustain
a TBI (Grimm & Bleiberg, 1986). Pepping and Roeuche (1991) have identified critical
stages at various times in the TBI recovery process. These stages, described as phases I
through VI, take into consideration the individual with TBI neurological status,
reactionary issues, and pre-morbid factors.

Phase one involves the trauma itself, and sub-acute functioning. The initial or
sub-acute phase encompasses coma and posttraumatic amnesia (PTA). An individual is
said to be comatose when there is an absence of eye opening, motor response, and verbal
response (Prigatano, Bruna, Mataro, Munoz, Fernadez & Junque, 1998). PTA refers to
an absence of memory for daily events and people, and lack of full consciousness (Long,
1989). The severity of TBI is defined by duration of loss of consciousness (LOC) (Morse
& Montgomery, 1992) or by severity of impaired consciousness on the Glasgow Coma
Scale (GCS) (Teasdale & Jennet, 1974). The GCS assesses level of consciousness and is I
based on a standardized cumulative score of eye opening response (E), motor
responsiveness (M), and verbal responsiveness (V) (Teasdale & Jennet, 1974). For
example, a score of 13-15 on the GCS indicates a mild TBI, 9-12 is a moderate TBI, and
a score of 8 or less is indicative of a severe TBI (Bond, 1990).

Post-coma disturbance occurs during this initial phase. This is defined as the
period between emergence from coma and the resolution of PTA. During this time the
individual with TBI may experience some acute confusion marked by attention

disturbances and an inability to maintain a coherent line of thought (Long, 1989).

24

Delirium, a common occurrence in the initial phase of recovery, is associated with
inadequate sensory stimulation, sleep deprivation, intense anxiety, disturbed interpersonal
relationships, and increased intra-psychic conﬂict (Slagle, 1990). Cognitive and
behavioral dysfunction can be observed in the individual’s confabulations, preservations,
distractibility, agitation, aggression, bizarre, impulsive, psychotic-like behavior, and
denial of their condition (Grant & Alves, 1987).

Neurological indices including early GCS scores, duration of coma and
unconsciousness, and length of posttraumatic amnesia have been considered important
predictors of cognitive functioning following a TBI (Haslam, Batchelor, & Fearnside,
1994). McClelland (1988) reports the general agreement is more severe initial TBI, as
assessed by neurological procedures, results in greater cognitive impairments. Klove and
Cleeland (1972) examined the relationship between neurological competencies and
cognitive outcome. They reported that the duration of unconsciousness was a signiﬁcant
predictor of outcome for patients assessed between 7 and 18 months post-injury. Shores
(1989) found PTA had a more reliable relationship to post-injury cognitive outcome than
did coma. Haslam et a1. (1994) examined early neurological variables in relation to
specific cognitive functioning (recent memory and speed of information processing) at
one year post-injury. Results revealed that cognitive ability of recent memory
functioning declined with increased post-coma disturbance time and the presence of a
subarachnoid hemorrhage. These studies as well as others (Brooks, Aughton, and Bond,
1972) reveal that early neurological factors may contribute to cognitive outcome

measures following TBI.

25

The sub-acute phase, or phase two involves the resolution of PT A and generally
lasts six months (Bond, 1975). During this phase, one of three transient syndromes can
emerge. These include organic excitement, paranoia, and aggressive behavior. Organic
excitement is manifested in euphoria, increased energy, rapid thinking and speech, and
psychomotor agitation (Grant & Alves, 1987). The second transient syndrome is
paranoia, characterized by suspiciousness about the motives of others (Prigatano, 1987c).
In an exacerbated form, delusions can involve persecutory beliefs, fears of illness and
death, jealousy, and paranoia (Gualtieri & Cox, 1991). Post-recovery delusions are
common during this sub-acute phase and attributed to the effects of cortical brain lesions
(McAllister, 1997). The third state is marked by aggressive behavior in concert with
mania, paranoia, and delirium (Grant & Alves, 1987). Aggressive tendencies associated
with PTA generally result from confusion and cognitive impairment (Moore &
Stambrook, 1995).

Phase three or post-acute phase is usually marked by considerable improvement
in both cognitive and language abilities (Rosenthal, 1983). The majority of spontaneous
recovery typically occurs in this post-acute phase, some 6 to 12 months post injury
(McAllister, 1997). Reacquisition of lost functions by intact neural networks, improved
motivation, and psychosocial adjustments are factors that account for improvements
during this phase of rehabilitation (Lishman, 1973). It is during this time that memory
for daily events, accurate recognition of others, and interpersonal behavior, all show
signs of improvement. During this phase the level of physical and emotional disability is
established, although minimally acknowledged by individuals with TBI and their family

(Bond, 1984). Phase three is seen as the most challenging period for individuals with

26

TBI and their family (Pepping & Roeuche, 1991). This phase is characterized by
increased insight or continuous setbacks. Many individuals with TBI enter a cognitive
rehabilitation program during this phase.

Many individuals with TBI are faced with confronting the extent of their
disability, or dealing with the expectations of what type of recovery will occur. This is
all part of phase four. When individuals with TBI psychologically deny their disability or
are cognitively unable to understand and accept their disability, coping problems can
result (Pepping & Roeuche, 1991). During phase four individuals with TBI who have not
accepted their disability tend to discontinue rehabilitation.

Phase ﬁve is where these individuals proceed to in order to passively engage in
rehabilitation. In order for success to occur in this phase, individuals with TBI must
constructively cope and accept their situation. Those who adapt by coping or at least
recognize that deﬁcits have been incurred accept cognitive retraining. Individuals who
comprehend their impairments, and embrace the therapeutic process are more invested in
their psychosocial adjustment. This involves affectively internalizing the functional
implications of impairment into one’s self-concept, coupled with behavioral adaptation
and social reintegration (Livneh & Antonak, 1990). In order to succeed, individuals with
TBI need to demonstrate social competencies by establishing and maintaining healthy
interpersonal relationships, proficiently enacting social roles, and ﬁnding their life
context and performance satisfying (Grant & Alves, 1987). In order to adjust, one must
maintain some level of emotional acceptance, while coming to terms with self, and the

environment. However, those individuals with TBI who remain unaware of their deﬁcits,

27

fail to cope effectively and continue to mispcrceive themselves and eventually have
difﬁculty accepting their new self (Pepping & Roeuche, 1991).
Etiology of Symptoms

Disturbances in thinking, feeling, and behavior are common post-injury
consequences. Three factors contribute to these interpersonal deﬁcits apparent in the
sub-acute and latter phases of recovery. These include reactionary factors, pre-morbid
personality, and neurologically based psychological problems (Pepping & Roueche,
1991).

Reactionary factors occur on an emotional level and involve disturbances reactive
to alternations in perceptions, capacities, and situations caused by the head injury
(Prigatano, 1987b). According to Livneh and Antonak (1990) reactions such as shock and
anxiety occur early, while acknowledgement and adjustment to the disability manifest
themselves later on. Recognition of reduced competencies and, more generally, a sense
of loss of self, are reactions to the residual effects of TBI (Cicerone, 1989). Denial,
anger, and depression often surface, in response to the emotional reaction, and in
association with neurological factors.

Pre-morbid personality is the second factor that may contribute to interpersonal
deficits following TBI (Morse & Montgomery, 1992). In discussing the signiﬁcance of
pre-morbid personality it has been noted, “it is not only the kind of injury that matters,
but the kind of hea ” (Symond, 1937). This statement punctuates the powerful effect
pre-morbid personality factors have one’s ability to manage changes in self subsequent to
TBI (Pepping & Roueche, 1991). Individuals with TBI who experienced a pre-injury

healthy and cohesive sense of self are more inclined to manage and accept

28

neuropsychological changes (Klonoff et al., 1993). These, however, with self-esteem
issues or narcissistic personality structure, experience difficulty with acceptance and
coping. This phenomenon termed “narcissistic rage,” describes the client who feels
helpless, ashamed, and revengeful, in response to recognizing the destructive impact that
perceived incompetencies have on their sense of self (Kohut, 1972). Pre-existing
personality, interpersonal, and adjustment issues can be accentuated by the individual
with TBI, and seriously compromise the recovery process. In particular, oppositional,
impulsive, dependent, obsessive, repressive behaviors, and issues with trust may likely
become magniﬁed following TBI (Crosson, 1987).

Oppositional behaviors, whether directly or indirectly displayed by individuals
with TBI, tend to hamper the restorative process. Issues surrounding dependence on
others can surface in those individuals inclined to rely on others. For example, an
individual’s progress can be delayed if he/she depends on caregivers to perform tasks as
opposed to relearning a lost skill. When faced with these situations, these individuals
may manipulate environmental factors, including people, in order to be served by them
(Crosson, 1987).

Frontal lobe injury tends to intensify pre-morbid impulsiveness, thus rendering
the person with TBI incapacitated to think before responding. These individuals, prone
to reacting without thought, now fail as they impulsively act and avoid taking
responsibility for their behavior. Obsessive thinking and compulsive behavior can
become compounded by cognitive inﬂexibility associated with neurological injury. In
order to avoid reality, individuals with TBI tend to repress information, which has the

potential to complicate the recovery process as they suppress anxiety-arousing

29

interpersonal difficulties associated with their deﬁcits. Consequently, these individuals
may fail to accurately process their actual intrapersonal reaction to the injury. Pre-
morbid issues with trust may contribute to difficulties in establishing relationships and
rapport with rehabilitation professionals.

Neurologically based psychological problems compromise the third factor
associated with post-injury interpersonal deficits. Neurological destruction directly
interferes with the brain capacity to be effective, resulting in cognitive, emotional, and
behavioral impairments. To fully appreciate the impact neurological damage has on
these aspects of human functioning, neuroanatomical structure and circuitry will be
explained.

The human brain is composed of a jelly like mass that is surrounded by
cerebrospinal ﬂuid within the skull and weighs approximately 3 pounds. It is home to
nearly 100 billion neurons, each acting as a tiny information processing system with
thousands of connections for sending and receiving signals to and from adjacent neurons
(Huffman, Vemoy & Vemoy, 2000). These neurons act as building blocks for the
nervous system, and function as an electro-chemical communication operation
responsible for controlling thought, emotion, and behavior (Anderson, 1980). The brain
consists of four subdivisions, the cerebral hemispheres, diencephalons, brain stem, and
the cerebellum (Davis & Palladino, 2002).

There are two cerebral hemispheres which account for approximately 80% of the
total brain weight (Myers, 1999). Each hemisphere has its own unique processing
responsibilities. The left hemisphere is associated with symbolic and analytical

processing, primarily involved with verbal and written language abilities, arithmetic

30

sequencing, and logic (Anderson, 1980). The right hemisphere is associated with
perceptional and spatial processing. It is the hemisphere associated with creativity, poetic
ability, insightfulness, intuitive thought, and having the ability to partake in art and
music. Each hemisphere is responsible for processing information on the opposite side of
the body. It should be noted, that although diverse in function, both hemispheres are
composed of the cerebral cortex (outer gray matter), internal white matter, and islands of
gray matter deep within the white matter (Davis & Palladino, 2002). The two
hemispheres are joined by the corpus callosum, a large band of neural ﬁbers that carries
messages between them. In addition, each hemisphere is divided into four lobes, or areas,
the frontal lobe (front of the head), parietal lobes (top and to the rear), the temporal lobes
(just above the ears), and the occipital lobe (located at the back of the head).

The cerebral cortex, or neocortex, accounts for forty-percent of the total mass, and
three-fourths of the neurons in the brain (Anderson, 1090). The cerebral cortex can be
conceptualized as a thin neural sheet, about the size of a large pizza. To ﬁt within the
skull the cerebral cortex is highly convoluted with many folds and wrinkles, appearing as
a bumpy surface. The motor, sensory, and association areas are contained within the
cerebral cortex. The prefrontal cortex is further divided into an orbital frontal and
dorsolateral region. Located at the anterior tip of the frontal lobes is the orbital frontal
region. The dorsolateral prefrontal cortex lies toward the back, and away from the
midline of the cortex.

Behind the motor cortex and in the front of the parietal lobes is the sensory cortex
(Myers, 1999). The parietal area, along with portions of the temporal and occipital lobes

provide for conscious awareness of sensation. The association area comprises the third

31

functional area of the neocortex. These areas, which make up a larger portion of the
cortex, communicate with the motor cortex and other sensory association areas to
analyze, integrate, and act on sensory inputs (Kassin, 2001). Association areas are used
for complex activities such as planning a weekend camping trip, solving a complex
mathematical operation, and creating a clay sculpture.

The brain’s second subdivision, the diencephalon, forms the central core of the
forebrain and is surrounded by the two cerebral hemispheres. The diencephalon itself
consists of three structures, thalamus, epithalamus, and hypothalamus (Myers, 1999).

While these three bilateral structures are all significant, the thalamus is of utmost
importance, as it is necessary for nearly all cortical activity (David & Palladino, 2002).
Eighty-percent of the diencephalon is thalamic structure, often referred to as the ‘inner
room,’ a name that describes its deep and well-hidden location below the corpus callosum
(Huffman et al., 2000). Appearance-wise, the thalamus looks like two small footballs,
situated side-by side atop the brainstem. Serving as the brain’s sensory switchboard, the
thalamus receives input from nearly all sensory systems. It then sorts, edits, and projects
this information to the appropriate area. A secondary thalamic structure, the epithalamus,
is positioned in the most dorsal portion of the diencephalon. The epithalamus is involved
in sleep-wake cycle, and mood.

A doughnut-shaped system of neural structures rests at the border of the brainstem
and cerebral hemispheres (Myers, 1999). This is known as the limbic system, an
interconnected group of structures involved with memory and emotional behavior,
particularly aggression and fear. The hypothalamus, which caps the brainstem and lies

below the thalamus, is included within the limbic system. Functionally, the

32

hypothalamus is the link between the endocrine system and nervous system, helping to
maintain the body’s internal environment in a steady state through the regulation of
hunger, thirst, and body temperature. Secondly, hypothalamic activity inﬂuences the
experience of pleasureful reward, behavioral and emotional control (Huffman et al.
2000).

Lying below the subcortical structures, and beginning where the spinal cord
swells as it enters the skull is the brain stem, the third subdivision of the brain. Because
of its innermost location, the brain stem is often referred to as the brain’s basement
(Myers, 1999). Brain stem centers, including the pons, medulla, and reticular formation,
produce rigidly programmed and automatic behaviors required for survival (Kasssin,
2001). The pons is located at the top of the brain stem, and in front of the cerebellum.
Primarily responsible for respiration, the pons relays communication between the motor
cortex and cerebellum, helping maintain a normal rhythm of breathing, orchestrating
movement and promoting sleep (Huffman et al. 2000).

Below the pens, just above the spinal cord, is the medulla. Like the pons, the
medulla is crucial to heartbeat and breathing. Located within the brain stem is the
reticular formation, a ﬁnger-shaped network of neurons, extending from the spinal cord
to the thalamus. Serving as a filter for incoming sensory information, reticular formation
sifts through and rejects irrelevant material. When this system has determined
information useful, it is then relayed to the appropriate part of the brain for further
processing. As a sensory ﬁlter, reticular formation is also important for attention and
arousal. For example, effective reticular formation attends to useful information, picks

up necessary cues, and responds to appropriate stimuli.

33

Accounting for 11% of the total brain mass, the cerebellum is sometimes called
the ‘little brain’ (Kassin 2001). This fourth subdivision of the brain, located at the base
of the brain behind the brain stem, is known for its role in maintaining smooth movement
and coordinating motor activity (Huffman et al. 2002). It is crucial to ambulation and
functional fine and gross motor activity. In relation, the cerebellum control automatic
adjustments of posture, enabling one to maintain an upright posture when walking and
sitting in a chair.

Structurally, it can be seen, that the brain is rather inuicate and sophisticated.
Brain regions, and subdivision parts, have designated abilities that join together in
creating a working brain. Operationally, structures and neural circuits are dependent
upon each other for optimal neural communication, which ultimately affects thinking,
emoting, and behaving. TBI, however, threatens this process by destroying brain matter
and disturbing neuronal communication. When the force of trauma is directly
transferred to the brain, neurological insult produces focal and/or diffuse damage. Focal
damage can be caused by a laceration or contusion at the site of impact, opposite the site
of impact, which is caused by the brain bouncing from one side of the skull to the other,
or by the brain rubbing against irregular areas of the skull (Pepping & Roueche, 1991).
The anterior temporal lobes and orbito-frontal cortex are common locale for focal type
injuries (McAllister,1997). These brain regions lie in close proximity to boney
prominences at the base of the cranial vault, such that upon rapid deceleration, the brain
is thrown directly against them (Grimm & Bleiberg, 1986). Because of the proclivity of
this boney structure to inﬂict damage to the orbital frontal cortex, it is irreverently

referred to as the “dashboard” of the brain (Varney & Menefee, 1993).

34

In addition to being anatomically large, the frontal lobes are complex,
heterogeneous, and they produce varied, yet significant dysfunction when severely
damaged (Duncan, 1986). Focal damage to the left frontal lobes is associated with verbal
deﬁcits, orbital lesions are associated with emotional changes, bilateral and diffuse
frontal lobe damage cause greater awareness difﬁculties than unilateral or focal damage,
and prefrontal lobe damage affects awareness of socially inappropriate behavior
(McClelland, 1988). Speciﬁc dorsolateral prefrontal lesions cause cognitive and memory
impairments associated with planning and the temporal organization of action. Most
severe cases of disorganized behavior occur with very large lesions, not always conﬁned
to the frontal cortex. Stimulus-bound behavior is a likely consequence of dorsolateral
prefrontal lesions (Long, 1989). This is observed when the individual with TBI is
compelled to spontaneously manipulate objects before them, or imitate odd and even
socially inappropriate behaviors of others. Stimulus-bound behavior occurs as the
individual with TBI is bound by environmental cues.

On the other hand, diffuse damage, results from shearing forces applied to axons
of cortical neurons. The axons stretch, twist, and break, causing neuronal disruption, and
consequent impairment. This type of damage, often referred as diffuse axonal injury
(DAI), occurs primarily in sub-cortical regions, such as the corpus callosum. The
damage creates decreased speed of neuronal processing, which consequently slows
thinking, analyzing, and integration of information (Morse & Montgomery, 1992). To
illustrate, DAI can be considered analogous to a closed lane on the highway. Although
cars can get through, the ﬂow of trafﬁc is slowed, and one hesitates to pursue rush hour

travel (Long, 1989). For the most part, DAI is more common than focal type injuries in

35

persons with TBI. It is because additional focal trauma from contusions, skull fractures,
and hematomas, create more widespread, or diffuse damage (Silver, Yudofsky & Hales,
1991).

Taken together, reactionary factors, pre-morbid personality, and neurologically
based conditions can result in a multitude of cognitive, behavioral, and vocational
problems for individuals with TBI. In part, this study investigates what impact cognitive
rehabilitation as an intervention strategy has on these factors.

Sequelae of Traumatic Brain Injury

Over the past two decades, research has documented the broad array of
neuropsychological impairments manifested by individuals who have acquired a
traumatic brain injury. After a traumatic brain injury, individuals can encounter a barrage
of deﬁcits including, physical, cognitive, psycho—social, and behavioral effects that can
pose a formidable obstacle in their personal and vocational life. Although the sequelae of
TBI are multidimensional in nature, many rehabilitation professionals still focus on
intervention from a unidimensional perspective. Cognitive, physical, psycho-social, and
behavioral impairments that are prevalent after TBI can interfere with personal and social
adjustment, and impede return to work and/or school thereby signiﬁcantly impacting the
individual’s ability to function effectively in everyday life (Dikman & Machamer, 1995;
Glisky, 1992; Johnson, Thomas—Stonell, & Shein, 1994).

Because of their organic impairments, individuals with TBI often are unaware of
their deﬁcits as well as their consequences. This lack of awareness of deﬁcits usually
results in poor response to cognitive rehabilitation interventions as well as unrealistic

expectations for the future (Rattok, Ben-Yishay, Ezrachi, Lakin, Piasetsky, Ross, Silver,

36

Vakil, Zide, & Diller, 1992). In order for successful rehabilitation and integration into
the community to occur, awareness and eventual acceptance of deﬁcits is often a crucial
aspect in the rehabilitation process. Individuals who continue to show a lack of
awareness are likely to have community re-integration problems (Ezrachi, Ben-Yishay,
Kay, Diller, & Rattok, 1991; Rattok et al., 1992).

Cognitive, physical, behavioral, and psycho-social sequelae of TBI include
difficulties with new learning, information retrieval, academic difﬁculties, perceptual and
motor skills deﬁcits, impaired capacities for control, regulation, and adaptation of
complex behaviors including impairments in problem solving abilities, difﬁculties
modulating cognitive activities, difﬁculties modulating emotional reactions typically
manifested as emotional liability, irritability, lack of initiative, depression, or
dishinibition disorders, and impaired capacity for self-control (Dikman & Machamer,
1995; Lezak, 1986; Rattok et al., 1992; Routh, 1987).

Physical Deﬁcits

Following traumatic brain injury, physical deficits may vary in type of
impairment and extent of disability. Physical deﬁcits are usually associated with damage
to the brain as opposed to the peripheral body parts. Physical deﬁcits may lead to a
number of conditions such as spasticity, which is commonly seen in persons with
traumatic brain injury and is characterized by a hyperflexive state of deep tendons with
increased muscle tone (Carew, 1985). Spasticity affects motor functioning and may
interfere with mobility and activities of daily living.

A loss of motor functioning may vary in severity from weakness to paralysis and

may affect any or all extremities. For example, monoplegia involves paralysis of one

37

extremity, whereas hemiplegia involves paralysis of both upper and lower extremity on
one side of the body. Paraplegia includes paralysis of lower extremities with
quadriplegia involving paralysis of both upper and lower extremities. Decorticate
hemiplegia involves paralysis including ﬂexion of the upper extremity and extension of
the lower extremity. Decerebrate hemiplegia includes extension of both extremities on
one half of the body (Nelson, 1983).

Individuals with TBI often experience disorders of movement and frequently
experience impediment in mobility and activities of daily living. Ataxia refers to a
discoordination of movement involving weakness and dyssynergy of movement. As
such, balance and mobility are frequently affected which may interfere with functional
activities particularly when there is upper extremity involvement. Ataxia is associated
with lesions of the cerebellum.

Apraxia is described as the inability to perform certain learned or purposeful
movements despite the absence of paralysis or sensory loss (Springer & Deutsch, 1985).
Apraxia may affect mobility and other functional activities. Kinetic or motor apraxia
results in difficulty in ﬁne movements such as holding a pen. Ideomotor apraxia results
in impairment in complex motor acts upon command although automatic motor acts are
less affected, and ideational apraxia results in an inability to formulate sequenced acts or
used objects involving sequenced motor acts (Springer & Deutsch, 1985).

There are numerous physical deﬁcits that can affect a person's functioning
following traumatic brain injury. However, only a few are mentioned in this study.
Prognosis in terms of recovery of physical abilities is uncertain. However, rehabilitation

intervention has been shown to prevent chronic abnormalities and to increase function.

38

Cognitive Deﬁcits

Despite the vast array of possible impairments as a result of traumatic brain
injury, cognitive changes have been the most widely studied in individuals with TBI.
Cognitive deﬁcits are manifested as difﬁculties in attention, memory, learning, and speed
of information processing due to brain damage (Crowley & Miles, 1991; Levin, Benton,
& Grossman, 1982; Routh, 1987). This determines the way in which an individual
experiences and responds to stimuli which in turn affects daily functioning (Ben-Yishay
& Diller, 1983). Deficits in cognitive functioning are perhaps the most prominent
features following traumatic brain injury. Levin (1985) stated, "outcome research during
the past decade has shown that chronic disability after severe head injury is primarily
attributable to neuro-behavioral sequelae, whereas motor and sensory deﬁcits are less
consequential for overall recovery (p. 281).

The impact on adaptive functioning due to cognitive deficits for persons with
traumatic brain injury has been well documented. As Ben-Yishay & Diller (1983) stated,
"by now it has been established with virtual certainty that the long term mental sequelae
outstrip the physical as a cause of difﬁculties with the vocational and personal
rehabilitation of the patient and with the problems encountered in the areas of living
arrangements, social re-adaptation, and strains on family life” (p. 171).

The psychological processes of attention and memory, cognition, and learning are
complex functional systems with their own inherent organization that works at an over-
leamed, automatic, level (Stuss & Benson, 1986). These systems involve various cortical
and subcortical regions in both hemispheres in the working of one function with different

regions participating in their own specialized way (Mesulan, 1981). Damage to speciﬁc

39

structures impedes the capacity of mental processes. For example, sustained attention
and concentration deﬁcits are associated with brain stem and thalamus damage, and
arousal problems are associated with brain stem compression. Frontal and prefrontal lobe
damage is related to selective attention, alternating attention, and divided attention
disturbances (Morse & Montgomery, 1992).

Executive functioning encompasses the processes and abilities involved in the
control of behavior (Grimm & Bleiberg, 1986). These processes relate to goal
formulation, planning, controlling a sequence of action, initiation, and insight (Shallice,
1982). Frontal lobe damage is most widely associated with producing deﬁcits in
executive functioning. The frontal lobes play a vital role in awareness of context and
gestalt and self-evaluation (Armstrong, 1991). Failure to recognize the problem or deﬁcit
results in one making repeated mistakes and refraining from utilization of compensatory
strategies.

Organization and planning involves figuring out the main points, sequencing,
coordinating, and formulating a plan (Varney & Menefee, 1993). This entails perhaps the
most complex of all activities, as it implies a capacity to integrate past and present
knowledge and perceptions, to make reasonably informed projections into the future
regarding multiple probabilistic consequences, and to anticipate the semi-independent
future state of the present situation (Grimm & Bleiberg, 1986). Disturbances in this area
are reﬂected in diminished efﬁciency with self-care, home management, and
interpersonal contact with others. For example, individuals with organizational deficits

are unable to logically organize and sequence their thoughts. When conveying

40

information, these individuals may present the information in a jumbled and incoherent
manner, leaving the listener uncertain regarding the content of the message.

Initiation difﬁculties may be evident in the presence of sufﬁcient motivation and
possession of a plan. This is apparent in the failure of individuals with TBI to initiate a
plan or make the required strategic shifts when appropriate (Grimm & Bleiberg, 1986).
Problems of this nature will likely result in persons with head injury having a decline in
their social relationships as well as vocational contacts. They are limited in their ability
to maintain the necessary behaviors required for reciprocal interaction with others
(Pepping & Roeuche, 1991).

Psychosocial Deﬁcits

The most pervasive characteristics of traumatic brain injury are changes that
occur in psychosocial functioning. These changes have a dramatic effect on lifestyle and
result in signiﬁcant psychosocial difﬁculties. Although residual cognitive and physical
disabilities may cause individuals with TBI to have signiﬁcant disabilities, it is the
emotional, behavioral, and personality manifestations of TBI that signify the greatest
difﬁculties for the individual and his or her family (Antonak et al. 1993). These organic,
reactionary, and psychologically based character changes are the signature of
psychosocial disturbance in TBI cases (Cicerone, 1989). As Prigatano (1987) stated,
"patients who suffer brain injury with neuropsychological sequelae have a personal
reaction to their deﬁcits. Moreover, their premorbid intellectual, personality, and
sociocultural characteristics interact with acquired brain injury to produce a complex
symptom picture, which often involves the disorders of personality as well as cognitive

functioning” (p. 1).

41

From an epidemiological view, persons acquiring a TBI are usually between the
ages of 14 to 25, and the residual deficits place great emotional, social, and ﬁnancial
burden on their families and a strong demand on rehabilitation services (Gainotti, 1993).
These individuals often exhibit social and self regulation deﬁcits, which result in an
inability to restrain impulses, use feedback to control their behavior, and evaluate the
consequences of their behavior. In addition, changes such as impaired initiative,
impulsivity, impatience, irritability, temper outbursts, and self centered behavior
(Zencius, Wesolowski, & Burke, 1990) often contribute and affect work capacity
(Gainotti, 1993). Moreover, lack of understanding or denial of deficits may affect the
individual's ability to critically evaluate their performance and set realistic goals.

Kaplan (1988) examined the effect of psychosocial variables on social and
vocational adjustment of persons with traumatic brain injury. Kaplan found that longer
comas and periods of posttraumatic amnesia were related to poorer vocational outcomes.
Additionally, "relationships were found between the family’s reported satisfaction with
their living situation, their adjustment to the subject's disability and the individual's post-
trauma return to the same or slightly reduced level of work or school responsibility” (p.
6). The following were not found to be signiﬁcant predictors of outcome: receiving
cognitive retraining, pre-injury alcohol or substance abuse, previous employment type,
age or marital status.

Four broad classes of psychosocial disturbance have been identiﬁed and include
anger, depression, anxiety, and psychological denial (Prigatano, 1987b).
One of the most common psychosocial consequences following TBI is anger

(Montgomery, 1995). As with other psychosocial disturbance, anger is an overt display

42

of personality and behavioral changes caused by the effects of TBI (Lezak, 1987).
Expressions of anger vary and may include some form of verbal abusiveness, self-
inﬂicted abuse, and, or physical aggression. These manifestations of anger create
intrapersonal and interpersonal hardship for individuals with TBI in every aspect of their
life (Delmonico et al., 1998). Moreover, individuals with pro-existing anger problems,
may experience exacerbations with this post-injury due to TBI generated dishinibition,
impulsivity, and poor pre-morbid coping (McAllister, 1997; Prigatano, 1987a).

Individuals with TBI usually express anger in the form of internalized anger or
extemalized hostility. Individuals who realize their impairment to be a chronic condition
as a result of an injury for which they are at fault are prone to experience internalized
anger (Antonak et al. 1993). In addition, internalized anger can be viewed as the
exhibition of self-directed bitterness and resentment commonly associated with self-
blame and guilt (Livneh & Antonak, 1990). Externalized hostility is usually directed
toward other individuals, objects, or aspects of the environment in response to limitations
as a result of the injury.

Anger usually surfaces when the individual with TBI realizes that they have lost
many abilities and drastic changes have occurred as a result of the injury (Crosson, 1987).
Anger is usually most apparent when the full impact of the disability is realized. Gans
(1983) stated that individuals with TBI in rehabilitation settings often despise the expert
role of staff members who are physically intact, capable of coming and going, living
independently, free from physical pain, and witness to the individual’s constant need for
assistance. External hostility can also beIdirected at family members, as individuals with

TBI feel powerless and perceive these signiﬁcant others as having power and

43

competencies they lack (Crosson, 1987). Family members may also play a role in
perpetuating anger. Lezak (1987) noted that families initially direct anger to those
responsible for the injury and then, through the course of rehabilitation, shift the anger to
rehabilitation staff. The families’ focus on anger further instills this thought process and
demeanor in individuals with TBI.

Individuals with TBI commonly express aggressive behavior directed at self,
others or property (McAllister, 1997). Kreutzer et al. (1990) stated that many factors
contribute to aggressive outburst in individuals with TBI. For example, premorbid issues
with low frustration tolerance and impulsivity contribute to the emergence of heightened
aggression for the TBI survivor. Frustration, consequent to feeling incompetent when
individuals with TBI fail to independently complete a simple daily task, can be viewed as
a reactionary response. Cognitive related problems increase the possibilities for
aggressive behaviors. These can include the inability to learn from mistakes,
understanding of behaviors relationship to consequences, self-reﬂectiveness, and insight.
Rosenthal (1983) stated that individuals with frontal lobe damage are disinhibited and
more prone to display aggressive and sometimes violent outbursts.

Depression is also commonly reported following TBI (Ownsworth & Oei, 1998).
Tyerrnan and Humphrey (1984) found 60% of individuals with TBI to be clinically
depressed when assessed 2 to 15 months post injury. More speciﬁcally, 52%
acknowledged they were “miserable and sad”, 44% reported losing interest in things, and
28% indicated life was not worth living.

. Manifestations of depression within individuals with TBI relate to numerous

losses, restrictions, and limitations imposed by the head injury. Feelings of loss due to

changes necessitated by the neurological insult causes individuals with TBI to be less
independent and more dependent on others socially (Lezak, 1978; Rosenthal, 1983).
These losses and changes have the consequent result of reducing self-worth and instilling
self-consciousness about the disability (Tyerrnan & Humphrey, 1984). Restrictions and
limitations as a result of TBI can inhibit individuals from participating in preferred social
activities and driving, which may be very important to them (Kreutzer et al., 1990).
Social isolation is very common among persons with disabilities, however, for
individuals with TBI social isolation is elevated. Such losses and limitations promote
feelings of hopelessness, helplessness, and worthlessness (Antonak et al., 1993). These
components of depression inadvertly affect individuals with TBI from effectively
working, socializing, and maintaining relationships. Persons with prior mental health
concerns, substance abuse issues, history of poor coping skills, lack of social and family
support, ﬁnancial difficulties, problems acquiring and maintaining employment face the
greatest risk of developing post—TBI depression (Kreutzer et al., 1990).

Blair and Lanyon (1987) conducted an experimental study evaluating the
effectiveness of an intensive, multi-disciplinary rehabilitation program upon a variety of
social and adaptive living skills in adults who were recovering from severe closed head
injury. The study also focused on how cognitive functioning is related to adaptive
functioning in the natural environment of such clients. The study assessed two areas of
functioning: (l) the adaptive living skills necessary for the individual to effectively
maintain personal independence in daily living and meet the social expectations of the
environment; and (2) cognitive deﬁcits which can seriously affect the client's overall

adaptation by interfering with the organization of goal directed behavior.

45

The study found that experimental group subjects signiﬁcantly improved their
adaptive living skills relative to subjects in the control condition. On the cognitive
scales, neither group showed any significant changes in cognitive functioning. The study
cannot conclude that changes in adaptive and social skills are related to changes in higher
cognitive functions. It appears that individual subjects showed obvious improvement
while others got worse. The authors recommended developing a different methodology,
which is based on knowledge of patterns and events that occur during the recovery
process and tailored to the individual's unique recovery sequence.

Lezak (1978) reported that the emotional disturbances such as depression, anxiety
and initability are commonly observed in persons with TBI. The author stated that these
disturbances often result from less observable problems such as perplexity, distractibility,
and fatigue. Perplexity may be characterized by a distrust of one's ability and may result
in response hesitancy and self-doubt. This may result from the client's experience of
decreased cognitive functioning and may lead to a variety of emotional reactions related
to decreased self-conﬁdence. Irritability is often associated with fatigue or distractibility
as the client is rendered ineffective in sorting out incoming stimuli and often feels
bombarded.

Another residual deficit of TBI is denial. Denial appears to be common in most
disability groups, and is thought to operate primarily as a psychosocial defense to cope
with overwhelming anxiety related to the onset of a disability (Falvo, 1991; Shontz,
1965; Wright, 1960). Denial is associated with a distorted perception of reality on the
part of the client. Deaton (1986) stated that this may be harmful to the patient as it

interferes with appropriate motivation and participation in the rehabilitation process.

46

It is often concluded that denial is seen in persons with TBI as the unawareness of
their deﬁcits. This may be organic etiology as in the cause of anosognosia. Anosognosia
is associated with right hemisphere injury and frequently is observed with left—sided
neglect (Hier, Mondock & Caplan, 1983). It is associated with damage extending
through frontal, parietal and temporal regions. The extent to which clients are capable of
making realistic appraisals of their abilities is associated with subsequent performance in
rehabilitation and may impact outcome (Lam, McMahon, Priddy & Gehred-Schulz,
1988). Denial may also be a manifestation of cognitive deﬁcits, which may prevent the
client from fully comprehending, integrating and appreciating deﬁcit areas (Baer, 1983).
Additionally, denial may occur as a psychological reaction to tragedy following traumatic
brain injury. Karpman, et al. (1985) stated that individuals with TBI are often unaware of
changes in personality or behavior despite others’ awareness of the changes. Prigatano
(1987) stated that unawareness of deﬁcit "is perhaps one of the major predictors of
outcome" (p. 10).

The same psychosocial issues that affect resumption of productive employment
also affect the interaction between family members who must cope with the client's
behavioral and personality disturbances. Gainotti (1993) stated that as a consequence of
the persons with TBI’s reduced interests for leisure and social interactions, and of their
lost working activities, both the individual with TBI and their family become socially
isolated. Kozloff (1987), noted that as result of isolation, the client's social network
undergoes two major modiﬁcations: (1) a reduction in its size as the number of people
interacting with the client decreases progressively; and (2) an increase in the intensity due

to the fact that the only persons remaining in contact with the client are those family

47

members who are committed to a lasting relationship with them. Being unable to return
to fulﬁlling employment and to maintain intimate relationships (Weddel, Oddy, &
Jenkins, 1980), these clients often become lonely and depressed if they have not been left
euphoric or apathetic by their injury (Oddy & Humphrey, 1980).

Oddy, Humphrey & Uttley (1978) reported in a study of 50 young adults who
acquired a TBI, they found disturbances in social functioning including a decline in the
number of close friends, a decrease in the frequency of social outings and an increase in
feelings of loneliness. According to Miller (1979) while substantial recovery often occurs
in intellectual functioning, significant readjustment problems may result in an overall
poor prognosis. Prigatano (1987) stated that the major problem a person with TBI faces is
the social isolation. As such, psychosocial adjustment might be the most salient and
pervasive long—term sequel of traumatic brain injury.

Personality deﬁcits can be viewed as those features observable in interpersonal
interactions. Personality features are inﬂuenced by psycho-social deﬁcits, however,
psycho-social deficits tend to be less stable over time, more malleable to change and are
usually associated with the affective state. It is important to note that in the area of TBI,
both psycho-social and personality deﬁcits are associated with decreased cognitive
functioning.

Personality change usually entails a reduction in initiation. Clients may be able to
verbalize what tasks they intended to perform and may be quite competent in
conceptualizing the appropriate order or sequence of steps in a given task. However,

tasks frequently go unmet and the client appears to lack motivation or drive. Pribram &

48

McGuinness (1975) stated that lesions, which interrupt the cortical-limbic reticular loop
often, result in hypokinesis and indifference. This may result in personality disturbance,
which presents as similar to a condition in which one is unmotivated (Bond, 1984).

When considered together, post-injury anger, depression, and denial all have the
potential to be inﬂuenced by organic, reactionary and pre-morbid factors. Because anger,
depression and denial can be detriments to the recovery process, these psychological
variables will be viewed in conjunction with cognitive retraining and overall
psychosocial functioning. As such, the aim will be to discover if any relationships exists
among or between these factors. If so, what are the clinical implications, and can
Cognitive Rehabilitation facilitate adjustment and promote awareness and eventually
improve employment outcomes?

Remediation of Memory Deficits

Memory impairments are a prominent theme in the lives of individuals with TBI.
Two types of amnesias, retrograde and anterograde, are known to occur. Retrograde
amnesia, refers to loss of memory for a period of time immediately preceding brain injury
(Long, 1989). More problematic is anterograde amnesia, as it renders new experiences
and facts lost or tangled in a confused web. Anterograde memory problems affect both
procedural and declarative memory. Procedural memory refers to the ability to
demonstrate knowledge about how a task is performed. Deﬁciencies with this aspect of
memory, is observed when an individual is unable to profit from past practice at the same
task (Grimm & Bleiberg, 1986). Consequently, individuals with TBI repeatedly make
the same mistake, leading to increase frustration, and serving to punctuate the presence of

deﬁcits.

49

Declarative memory pertains to declaring knowledge about facts or a situation.
When impaired in this area the individual with the head injury is unable to recall details
of the conversation, including persons involved and topic theme. Encoding, storage, and
retrieval problems are associated with declarative memory problems (Anderson, 1980).
Encoding problems appear in slow and ineffective processing. Storage problems are
evident when information is confused or confabulated over the period of time when it is
consolidated (Morse & Montgomery, 1992). Disturbances in retrieving information are
observed in those who simply cannot recall information presented. Some are able to
retrieve the facts, but personal reference to the memory is lost. That is, it appears as a
mere conceptualization of facts, because feelings of warmth and intimacy are not
conveyed (Prigatano & Schacter, 1991). This recalled information, previously personal
and episodic, has a detached and generic quality, and is presented as such to others.

Memory impairment is one of the major debilitating deﬁcits following head injury
(Glisky & Schacter, 1986). It can have an impact on all aspects of rehabilitation and can
disrupt an individual's ability to regain the most basic functions of every day living.
Levin (1985) stated that memory impairment is common following traumatic brain injury
due to the vulnerability of the temporal lobes to contusion and hematoma caused by
structural irregularity and bony protrusion of the sphenoid wing.

In the following section, I will use several studies that represent good statistical
studies to show the different statistics that were used. In addition, these examples
represent the different types of interventions used in many studies that were addressing

the impact of cognitive rehabilitation interventions on memory impairment.

50

Glisky, Schacter, and Tulving (1986) explored whether memory-impaired clients
could acquire the type of knowledge needed to operate and interact with a
microcomputer. Four clients with memory impairment took part in the study; three of the
four clients had developed a memory impairment following viral encephalitis. Each
client was tested in eight learning sessions, spaced over 2 or 3 days apart, with an
additional learning and test session 6 weeks later. The subjects attempted to learn two
lists of computer related terms, one by a method of vanishing cues, the other by a
standard anticipation method. At the start of each session, the subjects' knowledge of
both lists was tested by production and matching tests. This was followed by eight
learning trials on one of the lists, followed by another set of production and matching
tests. The above mentioned procedure was then repeated for the second list.

Results indicated that a proportion of words correctly produced showed an overall
increase across the eight learning sessions. The authors interpreted this increase to mean
that memory impaired clients are able to learn computer related vocabulary. Additionally,
results showed that learning occurred with the method of vanishing cues and with the
standard anticipation method.

Fussey and Tyerrnan (1985) investigated whether a general memory retraining
program would benefit clients with closed head injury who had severe memory
impairment within a medical rehabilitation unit. The subjects were four persons with
severe closed head injuries who were admitted to the Wolfson Medical Rehabilitation
Center between 7 and 9 months after the injury. Neuropsychological assessment revealed

that all subjects were severely impaired on a variety of memory tests. Of the four

51

subjects, three had suffered a reduction in general intellectual ability based on the
Wechsler Adult Intelligence Scale.

The memory retraining procedures used in the study were those advocated by
Grafman (1983). Each client was seen individually for 12 sessions over a one month
period, with tasks reinforced by workers throughout the day. Subjects were assessed
three times on a number of memory tests. Subjects were assessed initially to provide a
baseline, and a second time immediately following the memory retraining by an
independent psychologist. An assessment was completed one month after cessation of
the memory retraining.

Results showed no significant effect of training on memory. However, it was
noted that subjects were able to describe adequately the strategies taught when questioned
at follow-up. The author concluded that the application of a general memory retraining
program may not be justiﬁed within a medical rehabilitation unit. The author also
suggested that, with further general recovery of cognitive function, persons with head
injury may beneﬁt from memory retraining over a longer period of time, at a later stage
in the rehabilitation process.

Ryan and Ruff (1988) investigated the effectiveness of memory remediation,
using a combined number of mnemonic techniques and strategies aimed at improving
verbal and nonverbal memory capacities in persons with closed head injuries. The study
also compared the potential efficacy of these memory procedures in clients with mild to
moderate cognitive deﬁciencies.

The subjects were 30 potential clients recruited according to a number of criteria.

All subjects had received traditional rehabilitative interventions such as physical,

52

occupational, and speech therapies prior to being selected as a participant. However,
none had previously participated in a neuropsychological] y based treatment such as
cognitive remediation. The ﬁnal number of subjects who participated in the entire study
totalled 20.

The study utilized a counterbalanced experimental design, using random group
assignment. Randomization was achieved by assigning the subjects to either a placebo
control or experimental group while maintaining a balance according to demographic,
pre-screening, and neurological characteristics. Treatment lasted 6 weeks, 4 days a week,
5.5 hours per day for a total of 132 hours of placebo or cognitive remediation. Both
groups began each day with 50 minutes of group therapy and concluded with 20 to 30
minutes wrap up of the day's events.

Results revealed that the control and experimental groups signiﬁcantly improved
over time. Additionally, the experimental group did not demonstrate significantly greater
improvement than the control group. It was predicted that as a result of memory
remediation, the experimental group would demonstrate signiﬁcantly greater
improvement on all dependent measures as compared to the control group, which was not
supported. On the basis of severity of the neurobehavioral deﬁcits, results indicate that
subjects with mild neuropsychological impairments beneﬁted more from memory
remediation compared to the more severely impaired clients.

Crosson and Birenning (1984) designed a memory-retraining program using a
single case study design to evaluate a memory remediation program, which would meet
the daily needs of a person with a closed head injury. The subject was a 32-year-old

male who acquired a closed head injury following a motorcycle accident. The subject

53

had 16 years of education and was employed in a management position.

The client was referred for evaluation 2 months post injury. It was revealed from
the evaluation that there were periods in which the client experienced retrograde amnesia.
Especially noticed were large gaps in his memory for the 12 to 18 months immediately
preceding the accident. The client experienced an anterograde amnesia as well as a
retrograde amnesia. Evaluations of the client did not reveal any serious social or
emotional problems, however, the client did experience feelings of depression related to
the memory deﬁcit and physical injuries resulting from the accident.

The memory retraining program was designed to incorporate the clients' strengths
revealed during the evaluation. The training program was constructed to be
accomplished at the client's home because of commuting problems. The program
consisted of a close friend reading selected paragraphs, after hearing the paragraph once,
the client would write dowh all he could remember about the paragraph. At the end of
the week, the client would return with the written work, which was then scored. Each
paragraph consisted of between 23 and 58 ideas.

The program began 15 days after the original Wechsler Memory Scale (Form 1)
was administered. The Wechsler Memory Scale (Form 2) was administered at the end of
the program. Moreover, the Wechsler Memory Scale (Form 1) was administered as a
follow up 9 months after memory retraining. At the start of the program the client did
one paragraph per day with no particular strategy to help him remember. However, on
the 4th day of the program a strategy to aid in recall was introduced, and on day 7 and 10,

additional strategies were introduced until the client did four paragraphs each day. The

54

client did one paragraph using no strategy to aid his memory and three paragraphs using
three separate strategies to aid his memory.

Results indicate that the client had progressed from a relatively severe impairment
to a recall clearly within normal limits based on a comparison of the scores from the
Wechsler Memory Scale before and immediately after the memory program. On the
written paragraphs, results showed that the client progressed from a state where the main
idea of the paragraph was often lacking in his reproductions to consistently recalling the
main ideas. It should be noted that a 9-month follow up revealed some loss in memory
performance. In summary, the results suggest that persons with closed head injury can
improve their memory for complex verbal material with the aid of mnemonic techniques.

Levin and Goldstein (1986) investigated the ability of persons with closed head
injury to gain access to previously acquired semantic stores and to use such knowledge to
guide encoding and retrieval of new material. The study utilized an experimental
paradigm in which subjects attempted to learn word lists over repeated trial consisting of
unrelated words, related but unclustered words, or clustered (blocked) words at input.

The subjects were eight clients who were enrolled in the Transitional Learning
Community, a long-term rehabilitation facility in Galveston, Texas. Clients were
selected for this program because their overall level of functioning exceeds that of severe
disability; however, they are not suitable for independence and viable employment. The
control group members were matched according to age, sex, education, and occupation.
Subjects were individually tested in a single session lasting approximately 1.5 hours. The

memory condition consisted of free recall of the 18 words presented on four trials.

55

Subjects were required to recall the words in any order, including those words reported
on a previous trial.

After each trial recall was tested, this was followed by a new random presentation
of the same words previously heard. The sequence of the three conditions were
counterbalanced and separated by at least 20 minutes of neuropsychological testing
designed to evaluate various aspects of memory, semantic knowledge, information
processing, and problem solving skills. After completion of the fourth trial of a
condition, subjects were given cued recall by presenting the ﬁrst two or three letters of
each word. This was followed by a recognition procedure employing four choices for
each word (a phonemic associate, a semantic associate, an unrelated word, and the
target).

The performances of the two groups were compared by examining the number of
words recalled over for the three types of lists. Using repeated measures ANOVA,
results indicate a significant main effect for the subjects with closed head injury. In
addition, memory performance for the clustered list was better than for the unrelated, and
related-unclustered lists but the unrelated and related-clustered lists were not different
from each other.

Results of the study provide evidence for partially preserved semantic memory
following closed head injury. Despite the fact that controls demonstrated higher learning,
recall for both groups on the clustered list was better than for the unrelated and related
unclustered lists. The authors caution that while the performance observed is probably

representative of clients with similar backgrounds, injuries and outcomes, the results

56

should not be generalized to persons with severe head injury regarding their capacity for
memory enhancement by semantic organization.

The research suggests that while some persons with head injury can learn to use
these mnemonic strategies to enhance their recall of information, many others have
difﬁculties accomplishing this task. Visual imagery procedures appear to be dependent
on whether the mediators are supplied or self-generated, and the severity of the
impairment. Persons with severe head injuries appear to beneﬁt from externally
produced visual images, while persons with mild head injuries are able to generate their
own images. Future research needs to focus on whether these improvements can be
generalized to improvement in activities of daily living.

Remediation of Attention Deﬁcits

Another frequent area of impairment observed following traumatic brain injury is
in attention and speed of information processing. Deﬁcits in attention and information
processing including problems with task performance and distractibility were recognized
as sequelae of traumatic brain injury as early as 1904 (Gray, Robertson, Pentland, &
Anderson, 1992). However, it is only recently that research has shown that attention
deﬁcit has been a major cause of some of the challenging behaviors observed in
individuals with traumatic brain injury in rehabilitation settings (Gansler & McCaffrey,
1991).

Attention encompasses arousal, sustained attention and concentration, selective
attention, alternating attention, and divided attention. Arousal, or focused attention, is
reﬂected in overall alertness and the ability to tolerate various levels of stimulation

(Morse & Montgomery, 1992). In relation, common cognitive sequelae lead individuals

57

with TBI to experience problems monitoring what one is doing, processing information
one is reading or listening to, feeling overwhelmed by the situation, getting sidetracked
by their own thoughts, and heightened distractibility (Moore & Stambrook, 1995).
Socially, these deficits become apparent when these individuals are unable to process the
meaning and direction of the conversation. As a result, individuals with TBI may
become overwhelmed and fail to express themselves, or do so in a manner that reﬂects
reduced understanding (Ylvisaker et al., 1987).

Sustained attention and concentration refers to the ability to consistently maintain
attention to the task at hand. Long (1989), stated those deficits attributed to memory or
impaired problem solving may, in fact, be related to limitations with concentration and
failure to pay attention. Similarly, selective attention pertains to staying focused on a
task, while maintaining set (grasping the idea of what is asked of them), when faced with
distractions or extraneous stimuli (Morse & Montgomery, 1992). James (1890) noted that
selective attention involves reasoning, or the ability of the mind to break up the totality of
the phenomena reasoned about into parts, and to pick out the best conclusion.
Impairments in both sustained and selective attention contribute to slowed work
performance especially when tasks involve reading, intensive listening, or sustained
analysis, and frequent corrections (Ben-Yishay et al., 1987; Moore & Stambrook, 1995).
Within the context of a social or work situation these disturbances may impede an
individual’s effectiveness, thus limiting one’s ability to follow storyline details. Those
compelled to engage may present irrelevant responses, while others may simply withdraw

from activities, fearing embarrassment about their deﬁcits.

58

Alternating attention pertains to mental ﬂexibility, and having the capacity to shift
sets and hypotheses during a task (Pepping & Roeuche, 1991). Those with impairments
in this area demonstrate problems with listening and thinking simultaneously. In a
similar manner, divided attention requires one to monitor and respond to multiple pieces
of information all at the same time. Evidence of this type of dysfunction is apparent
when one gets stuck, or perseverates on a solution because of their cognitive inﬂexibility
and inability to completely process all the information (Morse & Montgomery, 1992).

Attention deficits usually manifest following the acute stage of recovery but may
endure for years post-injury. These difﬁculties can compromise attempts at rehabilitation
in other spheres since attention skills are multidimensional, include components related to
control or resource allocation, and are involved in all effortful cognitive activities.
Persons with traumatic brain injury are easily distracted, having considerable difﬁculty in
sustaining attention (Levin, 1985). Additionally, a lack of speed in processing
information may impede and interfere with daily activities.

Levin (1985) stated, "although severe closed head injured patients may eventually
regain the capacity to solve complex problems, they frequently require a much longer
period of time to reach the solution as compared to control subjects. In practical terms,
inattention and reduced speed of information processing detract from the patient's
adaptation to the work environment.” (p. 285)

Sohlberg and Mateer (1987) observed that deficits in attention and concentration
are often unrecognized or mis—diagnosed in the assessment of cognitive function
following brain injury. These authors further asserted that disruption of the

physiological systems, which regulate attention, might occur as the result of minor, as

59

well as severe neurological damage. Although the severity of attention deficits in persons
who are head injured may decrease over the course of recovery, signiﬁcant deﬁcits may
persist many months or even years after the injury.

As in the previous section, several studies that represent good statistical analysis
will be highlighted in this section. In addition, these studies represent examples of the
different and diverse types of interventions used in addressing the impact of cognitive
rehabilitation interventions on attention deﬁcits in individuals with TBI.

Sohlberg and Mateer (1987) examined the relationship between the
implementation of an attention-training model and changes in attention skills as measured
by the Paced Auditory Serial Addition Task (PASAT). The study utilized a multiple
baseline across cognitive areas in order to assess the effectiveness of the attention
treatment program. Four participants at the Center for Cognitive Rehabilitation, a post
acute day treatment brain injury program took part in the study. The subjects were
randomly selected from a consecutive series of admissions to the program, and varied in
the nature of their injury and time post onset. Each subject was tested individually using
the PASAT and the spatial relations subtest for the Woodcock-Johnson
Psycho-educational Battery, which was used to assess visual processing abilities.

Signiﬁcant impairment in attention skills and visual processing abilities were
identiﬁed for each subject. During the evaluation stage, two measures of PASAT
performance were obtained, and served as the baseline. At least eight measures of
performance on the PASAT were taken, with a minimum of two measures during each

treatment phases (before, during, and after attention training). The subjects received

60

between seven and nine individual cognitive retraining sessions per week, which focused
on attention, visual processing, or memory according to the treatment phase.

Results showed that subjects with mild to moderate attention deﬁcits had an
increase in attention skills to within normal limits, and those with severe attention deficits
achieved scores within the mildly impaired range following attention training. In all
cases, improvements in attention remained above baseline levels following termination of
speciﬁc attention training for periods as long as 8 months. Results demonstrated the
potential for improvement of attention deﬁcits in persons with head injury. Furthermore,
these findings suggested that, although improvements in attention skills can be seen
following any focused cognitive treatment, signiﬁcantly greater
improvement followed speciﬁc attention training.

Ponsford and Kinsella (1988) evaluated a computer~mediated program for the
remediation of deficits in speed of information processing among persons with brain
injury. The participants were 15 clients with severe closed head injury, between 16 to 45
years old, with no history of neurological or previous psychiatric disturbance.
Additionally, clients experienced a period of posttraumatic amnesia (PTA) for more than
24 hours and were less than 12 months post injury at the start of the program. Results
were analyzed at both a group and single subject level. Group means showed a gradual
improvement across all phases of treatment. However, a two way repeated measures
analysis of variance found no significant intervention effects on any of the measures,
although three of the subjects responded favorably to feedback and reinforcement.

The results indicated that subjects improved significantly over the course of the

study on both psychometric measures of speed of information processing and on a rating

61

scale of everyday attention behavior, which would be expected on the basis of natural
recovery of cognitive ability during the ﬁrst 12 months following head injury. However,
no conclusive evidence exists that when such recovery is controlled for, the participants
showed a signiﬁcant response to remedial intervention, which involved repeated practice
on computer-mediated attention tasks, designed to improve speed of information
processing.

Wood (1986) conducted a study to investigate a behavioral procedure for training
attention to task using a single case subject design. The study used two subjects, a 25-
year-old male and a l9-year-old female. Both participants had sustained severe head
injury four and six years earlier, respectively. Both subjects displayed problems of
attention, focusing on things that were not part of the therapy activity.

A time sampling procedure was used during therapy to record the client's
behavior. The subjects were recorded at two-minute intervals as either attending or not
attending to the therapy task. After a ﬁve-day period in which the baseline data was
collected, the training program was initiated. Plastic tokens were used to reinforce
attending behavior. Clients received a token at two-minute intervals only if they were
attending to the therapy activity at that time. Those who earned more than a designated
number of tokens exchanged them for a reward following the sessions. This method was
applied each day during two therapy sessions, for the duration of the training period, 28
days.

Results indicate that each client showed improvement in attending behavior
relative to baseline. However, one client showed significant improvement, with the other

showing improvement, but not at a signiﬁcant level. The authors suggest that this

62

discrepancy could have resulted from the application of different types of therapy activity
or the lack of set times during the day.

In a second study conducted by Wood (1986), using a single case design,
computer training tasks was used to investigate improving selectivity and speed of
information processing. Four subjects took part in the study, a 25 and 30-year-old male,
and a 19 and 46-year-old female. All had sustained severe head injury. The clients were
trained on tasks that required the maintenance of an attention set and efﬁcient
information processing. In order to determine if improvement in performance would
generalize to other aspects of behavior, two outcome measures were used; (1) a behavior
recording of attention during therapy activities (attention-to-task), and (2) measures of
auditory recall memory. On the auditory -attention task, each client was presented with a
sequence of digits at a rate of six digits per ﬁve seconds. At random intervals, a target
sequence of three odd digits was presented during the series. The client responded to the
target by tapping the top of the table. A total of seventy targets were presented in each
series, with 30 minutes duration for each task, once a day for 28 days.

In the visual attention task the client sat in front of a panel in which a
transparency containing 32 symbols was placed. The panel was divided into two matrix
panels, the right containing 16 symbols in different order, and the left containing 16
different symbols. The task began when a symbol in the left matrix was illuminated. The
client was required to move a scanning light across the top of the matrix until the light
position coincided with the column containing the target symbols, at which time the

client was required to stop the light. The task lasted 30 minutes for a period of 28 days.

63

Results of the study indicate a measure of improvement in both tasks using a
two-way repeated measures analysis of variance (ANOVA). The study also showed that
clients had a progressive improvement as training continued, which indicates an
improvement in their ability to process information more efficiently. The results also
indicate no difference in client's performance between the two training tasks, which
suggests that neither task proved too easy or difﬁcult and that both were useful training
procedures. More important, the results suggests that attention behaviors can be both
altered and improved with the use of contingent reinforcement which in turn improve
information processing capabilities.

Weber (1990) conducted a case study to investigate how the dimensions of
capacity and control manifest themselves during cognitive control. Capacity refers to the
amount of information or mental processing a person can attend to within a given time.
Control refers to a person's ability to guide the selective process by directing and
organizing whatever attention capacity the individual has.

The study investigated capacity deficit using a 37-year-old man who sustained a
closed head injury due to a fall. The client incurred no loss of consciousness, however,
neuropsychological evaluation 6 months post injury indicated severe attention deﬁcits
and possible mild memory deﬁcits with otherwise average intellectual functioning. The
client’s performance indicated slowed information processing and high stress levels.

The treatment program began 7 months post injury on a twice weekly basis for a
total of 3 hours per week for a total of 80 hours. The attention training consisted of
visual and auditory tasks presented on audiotape, computer, and paper and pencil. The

training tasks initially comprised very slowly presented stimuli for easy monitoring tasks

and simple reaction time measures. The speed and complexity demands were gradually
increased until the client was doing two tasks at once, and doing tasks involving ﬂexible
changing of attention focus. As part of the training, the client was provided with
homework assignments of reading, playing card games, and doing crossword puzzles in
order to increase attention activities at home. Relaxation training was also provided at
the beginning of the treatment to reduce cognitive overload and associated stress effects.

Results indicate that on the baseline performance, the client's performance
showed no evidence of improvement on the basis of practice alone. However, the retest
measures, which were identical to those of the baseline phase, showed dramatic
improvement. Retest scores indicate that the client's attention functioning reached
normal limits. The results also showed that after further training, the client has been able
to engage in simple business transactions with strangers for purpose such as selling his
car, ﬁnding a new apartment, and buying furniture.

In another study by Weber (1990), the author investigated control deficit using a
single case design. The client was a 59-year-old man who had suffered a series of
strokes. Treatment was initiated 4 months post stroke on a basis of 1 to 2 hours per week
for 6 months, for a total of 38 hours. The treatment focused on attention because
attention is the basis to other mental functions (Weber, 1990). The training utilized the
same task as described in the previous case. However, additional techniques, such as
changing from task to task, getting the client to make up his own tasks, role reversal (in
which the client monitors and scores the therapist's performance), and verbalization of

thoughts while doing the tasks were used.

65

Results indicate that although performance on the attention capacity test was the
same both before and after treatment, improvements have been observed on the attention
process measures. It was also noted that the client showed progressively more realistic
awareness of his performance and became more able to recognize and describe problems
he encountered both on the training tasks and with respect to activities of daily living.
The greatest impact of the training was reﬂected in the client's score on the Wisconsin
Card Sorting test. Prior to treatment, the client scored 2 standard deviations below the
mean with respect to errors, and 3 standard deviations below for categories achieved.
However, after treatment was completed, the client scored within normal limits on both
measures. Moreover, on the booklet form of the Category Test, the client improved from
3 standard deviations below the mean to 11/2 standard deviations below the mean.
Attention training was terminated after the client's functioning in everyday life reached an
acceptable level for the client and his wife.

Kewman, Seigennan, Kintner, Chu, Henson and Reeder (1985) conducted a study
to test whether a training program composed of a set of visuomotor and attention tasks
would generalize to a complex functional skill. Specifically, the study focused on
whether improving brain injured subjects' skills using a set of training tasks that simulate
different aspects of automobile driving would generalize to actual operation of an
automobile.

Three groups of subjects took part in the study. The experimental treatment group
consisted of 13 persons who were severely brain injured, this group received the full
training program with the AMIGO vehicle. The group consisted of 12 persons with

closed head injury, and 1 person with hypoxic encephalopathy. The second group of

66

subjects 11 persons with closed head injury, served as the control group and spent time
operating the AMIGO vehicle, but did not receive training on the specific tasks. A third
group of subjects was composed of 11 "normal" high school students who were licensed
drivers. This group trained on some of the tasks with the AMIGO vehicle. The average
age of the two brain injured groups was 24. 2 years old, while the average years of pre-
injury driving experience was 5.7 years. None of the persons with brain injury had
driven since their injury. All of the participants had been in a coma for at least 24 hours
and were a minimum 6 months (average 3.7 years) post onset of injury. No signiﬁcant
differences were obtained on the demographic variables between the brain injured
experimental and control groups, nor were there any significant differences in years of
education, weeks of hospitalization, or days in coma. Prior to training, the experimental
and control groups were compared on several cognitive-perceptual tests, which were
identiﬁed as sensitive to driving ability. On the Wechsler Adult Intelligence
Scale-Revised (WAIS-R), Symbol Digit Modalities Test (oral & written form), Motor
Free Perceptual Test, and Digit Span, no signiﬁcant differences were found; however, on
the picture arrangement of the WAIS-R scores were signiﬁcant with the experimental
group scoring higher than the control.

The procedure included pre-training evaluations and a training program. Each
participant's automobile driving performance was evaluated on city streets using the
same course. Subjects were evaluated on their ability to maintain lane position, execute
accurate turns, and observe specific road signs. During the training program, the
experimental group training consisted of eight 2 -hours driving sessions where subjects

were trained on seven driving related exercises using the modified AMIGO wheelchair.

67

The visual monitoring task consisted of the automatic presentation of a road sign at four
different points in the serpentine course. For the auditory monitoring task, clients
listened to a tape recording of randomly presented digits and words at a rate of one every
2 seconds.

Subjects were required to indicate a word as opposed to a numeral while they
negotiated the serpentine. Control subjects with brain injury attended eight 2—hour
sessions. They drove the AMIGO vehicles in each session for the same average number
of minutes as the experimental group, however, they did not receive special training as
the experimental group.

Results of the study indicates that prior to training, no statistically signiﬁcant
differences existed between the two groups on any of the driving tasks, composite scores,
or driver education ratings. However, after training signiﬁcant differences were observed
using the Mann- Whitney U test. Differences were observed for percentage of correct
tracking, percentage of correct signs, composite score, and driver educator ratings. Only
the measure of percentage of correct turns did not reach signiﬁcance. Overall, the results
showed that the AMIGO program with speciﬁc training exercises resulted in improved on
the road driving as compared to the AMIGO control condition without speciﬁc training
exercises. However, compared to the normal reference group, the experimental group
scored signiﬁcantly lower on all driving tasks.

The authors believe that as an example of remediation of attention and visuomotor
deficits following brain injury the ﬁndings have important implications for rehabilitation.

The ﬁndings showed that persons who are severely brain injured have the ability to

improve their performance with structured training long after their injury; and second,

68

performance on simple exercises that simulated aspects of a complex functional skill
generalized to the functional skill (i.e., automobile driving).

Niemann, Ruff and Baser (1990) evaluated the efficacy of a computer-assisted
attention-retrainin g program. The sample consisted of twenty-nine individuals between
ages 16 and 60 years. All had TBI in the moderate to severe range with a minimum coma
duration of 1 hour. The subjects all had chronicity ranging from 12 to 72 months, no
evidence of severe disorientation and confusion, sufﬁcient cognitive functioning, no
severe aphasia, sufﬁcient vision to read text on a computer screen, at least one functional
hand, no substance abuse since the injury, and no premorbid history of psychiatric
disorders resulting in hospitalizations.

Subjects were assigned at random to the experimental and control group. In order
to control for non-speciﬁc treatment effects, the control group received a memory
training of equivalent duration and intensity. Two subjects who enrolled in the attention-
training program (experimental group) discontinued their participation after
approximately 6 weeks for personal reasons. Training lasted a total of 9 weeks with two
2-hour sessions per week for both groups.

The experimental design evaluated outcome by juxtaposing a multiple baseline
procedure for the ﬁrst set of measures of attention and memory with a pre and post group
comparison that relied on a second set of neuropsychological tests. Results showed that
the experimental group improved signiﬁcantly in comparison to the control group on
measures of attention. However, the reversed patterns for the memory measures were not

observed.

69

Gray and Robertson (1989) conducted a study using microcomputers to provide
attention training tasks on self-modulation of arousal, and on alternating attention or on
dividing attention. Subjects were admitted for the trial if they fulfilled the following
criteria: (1) either subjective reports of difficulty in concentrating in real life situations,
such as reading or following a conversation, or reports of lapses in concentration by
relatives or care staff; and (2) either a score of one standard deviation below the mean or
lower on PASAT or more than five errors on the modiﬁed WCST.

The subjects were 31 clients with brain injury of acute onset who were randomly
assigned to an experimental attention training group and a control group. The 17 subjects
in the experimental group received between 13 and 18 hours of computerized attention
retraining. Each session lasted one to one and a half hours over three to nine weeks.
Retraining consisted of work on reaction time training, rapid number comparison; digit
symbol transfer and alternating strop program. The procedures utilized in the study were
expected to produce improvements in the experimental group on attention function as
measured by PASAT and WCST. However, subjects were measured on various aspects
of attention on controlled processing using a number of psychometric tests.

Results showed that only minor differences occurred in attention function. The
experimental group scored better on WAIS-R Picture completion and on the PASAT
Information Processing Rate. Scores also indicate that when estimated premorbid IQ and
weeks post injury were added as covariates, no signiﬁcant differences were obtained
between groups. However, the experimental group performed better by the sixth month
on a variety of psychometric measures such as Backward Digit Span, Arithmetic, PASAT

Total Score, PASAT Longest String, Information Processing Rate and Block Design.

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According to the authors, the results are not trivial, the experimental group improved by
an average of 2.14 points on Arithmetic versus 0.7 for the control group. In addition, they
conclude that the results are positive for the experimental group after a period of several
months.

Remediation of Socio-behavioral Deficits

Several studies that represent the different methods of cognitive rehabilitation
interventions on socio-behavioral deficits in individuals with TBI as well as used
effective statistical analysis will be highlighted in this section. Individuals with TBI
often exhibit deﬁcits in the social-behavioral and self-regulation areas. These individuals
often lack the ability to restrain impulses, use feedback to control their behavior, and to
evaluate the consequences of their behavior. Other characteristics changes may involve
impulsivity, impatience, irritability, temper outbursts, and self centered behavior
(Zencius, Wesolowski, & Burke, 1990).

In 1981, Luria proposed that the voluntary self-regulation of behavior is mediated
by “inner speech." Cognitive rehabilitation interventions have utilized self-instruction-
instruction to help individuals with TBI learn to regulate their own behavior. For
example, Cicerone and Wood (1987) successfully treated a 20 year old male client with
16 one-hour sessions of self-instruction training during practice of the “Tower of
London” task (see Shallice, 1982). During the training phase, the number of incorrect
moves decreased from an average of 176 to 2 per session. Following the training,
treatment continued with 12 sessions of self-instruction training in an interpersonal

setting. The result showed significant improvement in performance on the Self-Control

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Rating Scale. In summary, the results appear to demonstrate the efficacy of self-
instructional training in treating the behavioral sequelae of closed head injury.

Turner, Green and Braunling-McMorrow (1990) conducted a study using a
multiple baseline design to determine whether differential reinforcement of low rates
(DRL) would be an effective procedure to use with an individual with a TBI as part of an
intervention to reduce high rates of dysfunctional behaviors. The participant was a 21
year old male who was referred to a residential treatment program for individuals with
TBI. At the start of the study, the client was involved in behavioral intervention, physical
therapy, cognitive/communication therapy, living skills instruction and vocational
counseling.

Intervention entailed a full session of DRL with length of intervals and the
response requirements changing systematically across ﬁve intervention phases. When
the subject exhibited frequencies of behaviors in the combined verbal and physical
categories that were at or below a certain criteria for a speciﬁed time period, he was
awarded points. However, if he met or exceeded the weekly goal, he received monetary
rewards.

During the baseline period, behaviors in both the physical and verbal categories
occurred at a moderately high rate. After a week of intervention, a high rate of verbal
behaviors still occurred, but the goal of 3000 points was achieved. Results showed that
after the intervention, DRL procedures appear to be effective in reducing the rates of
socially dysfunctional behaviors. It should be noted that the intervention package also
included verbal instruction, social reinforcement, and token reinforcement. However, the

contribution of these on the effect of the client’s overall performance was not determined.

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Blair and Lanyon (1987) conducted an experimental study to evaluate the
effectiveness of an intensive, multidisciplinary rehabilitation program upon a variety of
social and adaptive living skills in adults recovering from severe closed head injury. The
study also focused on how cognitive functioning is related to adaptive functioning in the
natural environment of such clients. The study assessed two areas of functioning; the
adaptive living skills necessary for the individual too effectively maintain personal
independence in daily living and meet the social expectations of the environment; and
cognitive deﬁcits which can seriously affect the client’s overall adaptation by interfering
with the organization of goal directed behavior.

Twenty subjects took part in the study, 10 were full—time clients in a structured
rehabilitation program for head injured adults, while the remaining 10 formed a waiting
list control group. The rehabilitation group consisted of clients from the Hope Center for
Head Injury, a private, nonproﬁt day treatment facility which offers a comprehensive,
multidisciplinary rehabilitation program for head injured adults. Clients attended the
program six to seven hours per day, ﬁve days per week, and attended classes in activities
of daily living and social skills. The activities and skills were taught in the context of
individualized speech, occupational, and physical therapy; individual, group, and family
counseling; and a variety of other activities. Clients also attended individual and group
retraining sessions for cognitive dysfunctions with the particular activities selected to
meet each client’s individual needs. The control group consisted of clients who would
qualify for the Hope program and who were similar to the clients in the rehabilitation

group. The control clients lived at home, although some attended speech, occupational,

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or physical therapy once a week, whereas, others were engaged in a comprehensive
program.

Outcomes were measured using the Adaptive Behavior Scale (ABS), which
measured social and adaptive behavior. In addition, four broad areas of cognitive
functioning were assessed. Instruments included REACT, SYMBOL-Di git modalities,
WAIS—R comprehension, similarities, and arithmetic subtest; the visuospatial cluster
included the WAIS-R picture arrangement and block design subtexts. The memory
cluster included WAIS-R digit span subtest of the Wechsler Memory Scale (W MS).

The study ﬁnds that all t-values were less than 1.0, which demonstrates that the
groups were not signiﬁcantly different on the matching variables. However, on the
adaptive measures, the rehabilitation subject’s changes were greater in magnitude than
the control subjects changes in adaptive skills. On the cognitive scales neither group
showed any significant changes in cognitive functioning. The study cannot conclude that
changes in adaptive and social skills are related to changes in higher cognitive functions.
It appears that individual subjects showed obvious improvement while others got worse.
The study recommends developing a different methodology which is based on knowledge
of patterns and events that occur during the recovery process and tailored to the
individual’s unique recovery sequence.

Zencius, Wesolowski and Burke (1990) report on the use of a visual cue to reduce
profanity in three separate environments (speech therapy, occupational therapy, social
interaction class) in a person with brain injury. The subject was a 24 year old male who
sustained frontal and temporal lobe injuries after being struck by a car. The client was

referred for rehabilitation for drug abuse, poor interpersonal skills, poor communication

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skills, and inability to set realistic goals. Assessment using the WAIS-R revealed a
verbal IQ score of 76, performance IQ of 63, and full scale IQ score of 70. The client
also scored in the severely impaired range on the California verbal Leaming Test, the
Wechsler Memory Scale-Revised, and the Visual Memory Rey-Osterreitch CFT Test.
Moreover, on the Wisconsin Card Sorting Test, the Porteous Maze Test, and the Trial
Making Test, Part B, which measured impulsivity, the client scored in the severely
impaired range.

The dependent measure was the frequency of profanity used in each of the three
classes per day. During base line, the number of profanities used in each class per day
was scored. After base line, a sheet of white paper was held in front of the subject with
the word “swearing” written at the top with a red marker each time he used a profanity.
After using the visual cue a total of 26 days in the social interaction class, 24 days in the
speech therapy class, and 21 days in the occupational therapy class, the treatment was
discontinued. After treatment the participant was transferred to a less restrictive setting,
where he engaged in full time vocational programming.

Results showed that implementation of the visual cue in the social interactions
class decreased profanity to a mean of 0.5 per class per day as compared to 6 during
baseline. In speech therapy class profanity decreased from a mean of 5.8 per day during
base line to a mean of 0.8 per day, and in occupational therapy class profanity decreased
from a mean of 4.5 per day to an average of 0.3 per day. The results obtained showed
that profanity can be reduced using a visual cue to remind the client of his verbal

behavior. Zencius et al. (1990) suggest that the paper with the word “swearing” on it

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may have served as a stimulus controlling the verbal behavior of the client in a given
setting.

Alderman (1991) conducted an A-B-C single case study design in which
avoidance behaviors were treated by satiation through negative practice following the
failure of several behavioral programs. The subject was a 24 year old male who
sustained a severe closed head injury. Neuropsychological assessment revealed average
level of intellectual functioning. Testing also revealed that verbal skills were within
defective levels, memory functioning was globally depressed, and perceptual and
language skills were grossly intact.

At the start of the program, the client presented three major concerns: (1) a
general dishinibition of sexual behavior characterized by making inappropriate comments
of an overtly sexual nature towards, and by touching female staff members; (2) despite
the ability to self-toilet as the need arose, the subject urinated upon himself several times
a day; and (3) the client engaged frequently in very loud prolonged period of shouting
that would disrupt any activity he was scheduled to do.

Time-sampling methods were used to record a pre-treatment baseline of the
client’s shouting. Over a ﬁve day period of 9.5 hours of sampling, the client had a total
of 99 shouting episodes. Treatment took place twice each day, one in the morning, and
the other during the afternoon, and consisted of two 30 minutes individual session. In
addition to the intervention, the client was prescribed 100 mg BD of propanalol.

Results indicate a significant downward trend in the frequency of shouting.

Moreover, after withdrawal of the behavioral component the downward trend in shouting

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continued. Also, there was a significant decrease in the mean frequency of shouting and
screaming per hour.

The authors conclude that the results obtained showed that the intervention
demonstrated that negative practice as a treatment method is effective in reducing the
frequency of a negatively reinforced avoidance behavior. In relation to the client’s
disinhibited sexual behaviors, time out programs were used, which proved effective. The
results also indicate that when individuals with TBI develop behaviors in order to avoid
participating in therapy activities, the use of satiation through negative practice may
prove effective.

Vocational Outcome Studies

After reviewing the literature, it is clear that traumatic brain injury is associated
with a number of deﬁcits in areas of physical, cognitive, psychosocial and behavioral
functioning. Additionally, as the severity of injury increases these deﬁcits are likely to
become more apparent and debilitating. It is apparent that employment following
traumatic brain injury is a complex phenomenon with considerable disparity in reported
outcome statistics across studies. To attest to the fact that employment following
traumatic brain injury is difficult, studies have been conducted for the past ﬁfty years on
vocational outcomes following traumatic brain injury with no conclusive evidence.

In reviewing the literature on vocational outcome following traumatic brain
injury, a number of red ﬂags were discovered. First, there exists a problem related to
severity of injury. Many studies did not differentiate between mild, moderate or severe
brain injuries, which could have serious impact on those studies’ results. This is

important to note because level of severity has a strong correlation with residual deﬁcits

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Meta Analysis 78

and employability. Secondly, some concerns are apparent in the way work and/or
employment is defined in many of the studies. Some studies define work as part-time
employment, whereas others define work as full time employment or even volunteer
(non-paid) employment. This becomes important when trying to define a successful
vocational outcome. Thirdly, as previously mentioned in the recovery section, there are
some concerns related to pre-injury status. Many studies did not differentiate the
individuals' level of pre-injury education, employment or even personality and social
status, which according to most studies have an effect on level of recovery and vocational
outcomes. With these concerns in mind, a review of the vocational literature will be
undertaken.

Gjone, Kristiansen & Sponheim (1972) studied 94 persons with severe intra-
cranial injuries with an average length of hospitalization of three months. Forty-seven
percent of these individuals were suitable to return to work at discharge. However, less
than half of the 45 individuals who were classiﬁed as work ready were able to return
successfully to work.

Brucker & Randle (1972) followed 64 individuals with severe head injury (PIA >
24 hours) for a period of three years. They noted that 40% of these individuals had
returned to their pre-injury job and were receiving the same pay level. Twenty-four
percent returned to a lower employment level with correspondingly less pay, and 35%
remained unemployed. The authors concluded that the psychological symptoms
expressed by these individuals were the most significant barriers to employment.
Additionally, they found that factors such as age, epilepsy, hemiplegia and dysphasia

were viewed as obstacles toward successful employment.

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VanZomeran & VanDenBurg (1985) reported on a follow-up study of 61
individuals with severe head injury (PTA > 1 day and average duration of post-traumatic
amnesia of 30.5 days). Results showed that 58% of the individuals returned to their
former employment, 13% returned to their previous job with modifications, 5% were
employed at a reduced capacity, 7% were employed in sheltered workshops, and 16%
were unemployed. The authors concluded that the duration of post-traumatic amnesia
correlated with the ability to be employed, and identified 13 days of post-traumatic
amnesia as the cutoff point, after which an increasing emergence of personality
disturbances are observed.

Ben-Yishay, Rattok, Lakin, Piasetsky, Ross, Silver, Zide, & Ezrarchi (1985)
offered statistics on 100 individuals with severe head injury (loss of consciousness > 1
day). The vast majority of these individuals were at least two years post-injury and a
large number were unemployed at the time of admission to an outpatient program.
Additionally, the majority exhibited difﬁculties in attention, insufficient awareness of
deﬁcits, impulsivity, difficulties in learning, inadequate interpersonal skills and other
problems. Results indicated that 65% of these individuals who completed the program
where competitively employed. In addition, 15% entered sheltered employment with the
remaining 20% unemployed.

A study by Scherzer (1986) found that, after a three-year comprehensive
rehabilitation program, improvement was noted in areas of attention, visual information
processing and manual dexterity. Of the 32 individuals in the treatment program, six
returned to pre-injury level employment, four were temporarily employed, an additional

four were considered ready for employment and 18 remained unemployed.

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Kaplan (1988) followed 25 individuals who had acquired a severe head injury
with an average length of coma of nearly 10 days. Length of coma and duration of
post-traumatic amnesia were negatively correlated with successful re-employment.
Additionally, family adjustment measures on pre-injury functioning were associated with
more adaptive coping strategies following their injury. These measures were associated
with successful re-employment. Psychosocial adjustment and interpersonal skills were
found to be more predictive of successful vocational outcome than specific vocational
competencies. The author concluded that caution should be exercised in terms of the
value of cognitive remediation and urged that greater emphasis be placed on interpersonal
skills training and psychosocial adjustment.

Thomsen (1984) followed 40 individuals, 28 males and 12 females with severe
head injury (PIA > 1 month) over a 10-15 year period. Results revealed that of the 40
individuals, two were employed full-time, four were employed part-time, and an
additional seventeen individuals were in sheltered workshops. Also, three of the female
individuals were classiﬁed as being homemakers. The author concluded that brain injury
consisting of brainstem damage was a negative prognostic indicator, being associated
with prolonged dysarthria and motor impairment.

Cognitive Rehabilitation

Cognitive rehabilitation has gained tremendous prominence as a treatment for
individuals with memory and attention deﬁcits due to TBI over the past 20 years. As
previously stated, the survival rates for individuals with TBI has increased drastically due
to neurosurgery research, improvements in neurosurgical techniques, new forms of

pharrnacotherapy, and improved emergency care at accidents sites, including expeditious

80

evacuation to hospitals trauma units (Wehman et al., 1989). As such, rehabilitation
professionals are faced with treating individuals with more severe and debilitating
injuries.

Individuals with TBI pose a major challenge to rehabilitation counselors,
psychologists and other health care providers because of the complex nature of the
deﬁcits. Thus, appropriate rehabilitation programming is necessary if successful
reintegration of individuals with TBI is to occur. Over the past two decades,
rehabilitation facilities and clinics for individuals with TBI have increased dramatically.
With the recent inclusion of cognitive rehabilitation as a treatment technique, there has
been a signiﬁcant increase in brain injury rehabilitation facilities. In the past ten years,
there has been a signiﬁcant increase in the use of cognitive rehabilitation as an
intervention strategy for individuals with TBI. As more individuals survive TBI, the
focus has been on the improvement of cognitive functioning (e.g., memory, attention) and
improvement in daily living skills. The most advance has been the development of
programs designed to help individuals with TBI retum to independent living in the
community (Wehman, Kreutzer, Sale, West, Morton, & Diambra, 1989).

Individuals who have sustained traumatic brain injuries often experience
significant impairment in memory, attention, personality and behavioral functioning due
to pathophysiological alterations in the brain. Cognitive deﬁcits usually interfere with
successful reintegration into society, especially vocational and educational settings as
evidenced by their inability to maintain employment as well as high dropout rates due to
school failure (Johnson, Thomas-Stonell, & Shein, 1994). Research in brain injury has

demonstrated the differences in cognitive functioning among individuals who have

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sustained a TBI. Regardless of the severity of the injury, most individuals who have
acquired a TBI are likely to express some impairment in functioning compared to normal
controls on tests of reaction time, ﬁne perceptual judgment, memory, information
processing, and learning of new information (Sunderland, Curry, Das, Enderby, Kinsey,
Mortley, & Petheram, 1992). Given the impact of cognitive functioning on vocational
outcomes and quality of life, brain injury rehabilitation has shifted focus from one of
physical restoration to emphasis on improving cognitive functioning in individuals with
TBI (Crowley & miles, 1991).

Cognitive rehabilitation has become a focus for neuropsychologists and
rehabilitation practitioners who are involved in the treatment of cognitive deﬁcits in
individuals with TBI. Although no evidence exists to support any treatment interventions
or a speciﬁc cognitive rehabilitation strategy that could speed up the recovery process,
there is evidence that supports the timing of rehabilitative interventions as a crucial
indicator of recovery. Neurologically, there exists a period maximal reorganization of the
brain in the first few weeks post-injury. As such, it is crucial that rehabilitation efforts
begin as soon as possible following the injury. Additionally, Larkin (1993) stated that
rehabilitation intervention with individuals with TBI should continue as long as possible
because significant gains may still occur.

Deﬁning Cognitive Rehabilitation

Many terms have been used to describe cognitive rehabilitation. Such terms
include rehabilitation, remediation, and retraining which are frequently used
interchangeably in the ﬁeld as well as in the literature. Some in the ﬁeld of cognitive

rehabilitation have argued that there are differences in the terms rehabilitation,

82

remediation and retraining because the focus of the interventions are different. However,
regardless of the term, the purpose of cognitive rehabilitation is to improve functional
adaptation in daily living activities for individuals with TBI as determined by vocational
and academic functioning and community integration (Wheman et al., 1989; Wilson,
1991).

Diller and Gordon (1981) deﬁne cognitive rehabilitation as a form of intervention
in which, a constellation of procedures are applied by trained practitioners to provide
individuals with brain injury with the skills and strategies needed to perform tasks that
are difficult or impossible for them, due to the presence of underlying cognitive deﬁcits.
Cognitive remediation as deﬁned by Fujii (1996) is teaching individuals with brain injury
the skills and behaviors that they are deficient in due to their underlying cognitive
deﬁcits. Wehman et al. (1989) deﬁne cognitive remediation as "a group of strategies
intended to help persons with cognitive dysfunction to improve intellectual, perceptual,
psychological, and behavioral skills" (p. 69). On the other hand, cognitive retraining as
deﬁned by Berrol (1990) is a systematic attempt to improve intellectual deficits caused
by a brain injury that resulted in informational processing difﬁculties. According to
Berrol (1990), cognitive rehabilitation is more comprehensive in scope than cognitive
retraining and cognitive remediation, in that the brain can develop new neuronal
connections after an insult or injury given time and proper stimulation.

The aim of cognitive rehabilitation is to restore an individual’s cognitive abilities,
including memory, attention, concentration, organization, planning, and perception.
Cognitive rehabilitation according to Luria's concept of functional reorganization is a

four step process which involves: "the precise qualification of the psychological function,

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utilization of automatic and intact functions, a step-wise program with the aim of
integrating and automatizing, and continuous evaluation and feedback" (Christensen,
1986, p. 17). When working with individuals with TBI, Zangwill (1947) suggests that
the three most useful techniques in cognitive rehabilitation are the use of compensatory
strategies to bypass the deficit, the use of substitution to solve a problem by a different
means, and attempts to retrain the deficit.

Psychologists and rehabilitation professionals involved in cognitive rehabilitation
with individuals with TBI, often approach rehabilitation with the following goals: 1)
teaching clients to be aware of residual deﬁcits and the effects this will have on the
rehabilitation process; 2) teaching compensatory strategies designed to circumvent
functional disabilities; and 3) helping the individuals to understand and accept the
consequences of their brain injury as well as the permanent changes that may occur
(Prigatano, 1987). The goal of cognitive rehabilitation according to Wilson (1991) is
restitution of function and the use of compensatory strategies that capitalize on residual
skills. Thus the goal of cognitive rehabilitation in brain injury rehabilitation is to help
individuals regain functional abilities, which in turn will help them to become
independent and lead productive lives.

Cognitive rehabilitation can be applied with children and adults, and there is
growing evidence that indicates that various forms of cognitive rehabilitation are useful
in remedying intellectual deﬁcits in the elderly (Powell & Whitla, 1994). However,
controversy exists in the application of cognitive rehabilitation as to whether intervention
should focus on developing speciﬁc skills or improving basic cognitive processes.

Gianutsos (1992) stated that what is important is that as treatment progresses during the

84

course of recovery and as individual needs and resources change, intervention strategies
should be redefined and change to best suit the individual needs. As such, the primary
purpose of cognitive rehabilitation is to help accelerate the process of individuals with
TBI regaining their functional capabilities, and become productive members in society.
Historic Perspective of Cognitive Rehabilitation

Cognitive rehabilitation as a field dates back to the late eighteen hundreds, early
nineteen hundreds. John Hughlings Jackson laid the early foundation in 1897 for the
ﬁeld of cognitive rehabilitation (cited in Prigatano, 1987). His position was that higher
cerebral functions were less complex in their structural organization than lower brain
functions. The implications that stem from such a belief were that higher cognitive
processes were more modiﬁable than lower cognitive processes. In 1924, Flourens in his
work with pigeons, found recovery of higher cognitive functions after cerebral oblations
(cited in Prigatano, 1987). In 1927, Lashley's research yielded the same results with his
work with rats. Lashley (1938) concluded that recovery of higher cognitive functions
could be the result of a number of reasons. He posited that, "functional loss may be
secondary to destruction of essential neurostructures, temporary disruption of existing of
existing pathways, diachisis, metabolic disturbances, or lower tonic level of activity" (p.
735). Researchers have concluded from these studies that the potential for recovery of
higher cognitive functions appear to be greater than other functions mediated by the
central nervous system.

Cognitive rehabilitation appears to have its roots in World War II. Luria while
working with soldiers with penetrating gunshot wounds during the war, designed head

injury rehabilitation programs that were based on available scientific evidence. Luria

85

rehabilitation methods were eventually based on his theory of brain functioning
developed while working with these head injured soldiers (Luria, 1963). Interest in head
injury rehabilitation subsided until psychologists at New York University Medical Center
in 1962 started to address the issues at the interface of clinical neuropsychology and
rehabilitation. This work gave rise to intervention—based programs for individuals with
cognitive deﬁcits as a result of TBI, stroke, or other type of brain damage.
Neuropsychology as a field was not a formal discipline and rehabilitation psychology was
still evolving with a focus on dealing with disability from a personal and societal
perspectives. Diller (1992) stated that clinical neuropsychology in the 1960's developed
along three perspectives: (1) it provided the psychometric tools that would extend and
quantify the clinical neurological examination and thus make the use of proﬁle analysis
possible; (2) it provided the behavioral anchors for the subsequent explosion in
neuroimaging techniques; and (3) it provided for the examination of brain-behavior
relations through clinical and experimental methods to formulate more precise
descriptions of neurological syndromes.

The 1960's saw rehabilitation psychology operating under a multidisciplinary
approach. Specialists from different disciplines treated disability related problems with
the focus of the rehabilitation being on functional and practical abilities, and assessment
driven by functional considerations. Neuropsychological rehabilitation and cognitive
remediation as a specialty did not exist at this point in time. Cognitive rehabilitation as a
ﬁeld developed in the late 1960's and early 1970's due to the increase in survival rate for
individuals who sustain TBI. The early 1980's saw tremendous growth in the

development of cognitive rehabilitation and brain injury rehabilitation facilities. Prior to

86

the development of cognitive rehabilitation, brain injury rehabilitation mainly focused on
physical and speech restoration. However, with the development of cognitive
rehabilitation, interventions and treatment have addressed issues such as attention,
memory, perceptual motor difficulties, cognitive disorganization, eye movements, socio-
behavioral and self-regulation deﬁcits. Cognitive rehabilitation as an intervention
strategy has been shown to increase clients’ academic, vocational, and social areas.
Moreover, studies show improvements in formal psychometric measures. Presently,
cognitive rehabilitation interventions are used not only to treat persons with TBI, but also
children and adults with learning disabilities, and individuals with mental retardation
(Berrol, 1990; Routh, 1987).
Theoretical Foundations Underpinning Cognitive Rehabilitation

During the early stages of cognitive rehabilitation in the late 1970's and 1980's,
the major criticism was that there was not enough solid research to substantiate that
cognitive rehabilitation made a difference. However, with the advances in technology in
the past 20 years, researchers have revolutionized how the brain is studied. Computer
technology, in particular, has had the greatest, most significant impact in this area. The
advances in cognitive science have supplied the models on which cognitive rehabilitation
methods are based. As noted by Lucas (1992), cognitive rehabilitation strategies will be
reﬁned further and the reputation and scope of the ﬁeld of cognitive rehabilitation will
continue to grow as knowledge of the brain increases.

Within the field of cognitive rehabilitation it has been suggested that it is
necessary to base interventions on a theory of brain functioning and/or brain behavior

relationships. Clinicians recognize the relationship between basic neuroanatomy and

87

behavior; however, differing views still exist regarding how brain and behavior interact.
Despite these views, what is known and widely accepted about recovery after TBI is that
neural regeneration is very limited in the central nervous system, and improvements
through natural recovery may account for improvements assumed to be attributable to
cognitive rehabilitation (Wilson & Patterson, 1990). With this knowledge, one of the
theories underlying rehabilitation after TBI is that enhancement of residual abilities is
possible while restoration of impaired functions is not. An important aspect of cognitive
rehabilitation is to determine what deﬁcits are amenable to rehabilitation and which are
not. As such, the areas of deficit believed to be amenable to rehabilitation were
addressed by providing persons with TBI with the correct experiences in the context of
the appropriate level of demands such that they would have to develop the skills to
overcome or satisfy the demands (Bracy, 1994).

Cognitive rehabilitation methods within the past decade or so can be attributed to
the ﬁeld of information processing models of cognition from the field of cognitive
science. One theory underlying cognitive rehabilitation is the building block theory. In
this approach, cognitive skills are broken down into their component parts and these
component parts are practiced intensively in a stepwise fashion until mastery is achieved.
Another proposed model drawn from behavioral science, bases cognitive training
hierarchies on observable interactions of the individual with TBI and their external
environment. This model is seen by many researchers to be more consistent with how
behavioral skills are acquired and generalized than the cognitive information-processing

model (Levin, 1991).

88

In their discussion regarding the relationship between cognitive theory and
rehabilitation research, Caramazza and Hillis (1993) raised the issue of what exactly a
rehabilitation professional needs to know regarding a client's cognitive impairments in
order to determine what types of interventions will produce positive results. This issue is
important since, on the surface, two clients may produce the same performance on a task
but further analysis may reveal differences. These differences may be reﬂective of
different areas of damage, which may necessitate different kinds of intervention.

Many researchers have argued that rather than relying on theory to guide
rehabilitation interventions, treatments found to be effective with clients with similar
types of functional lesions should direct treatment. The type of approach is concerned
with the identiﬁcation of client categories for which information about the effectiveness
of various treatment strategies can be collected and used to develop treatment plans.
However, critics of this approach argue that interventions based upon this client
generalization paradigm can be dangerous because treatment may not be effective for
many reasons including differences from client to client with regard to severity and
nature of neurological damage, variations in the stage of neurological recovery, and
variations in the manifestations of deficits with damage to the same area. In addition,
differences in premorbid or residual abilities and premorbid client characteristics have
been found to be significant characteristics (Caramazza & Hillis, 1993).

To date, the six-factor model developed by Sachs, Bell, Berger, Carroll,
Davidson, Heavener, Peters, Schaffer, & Stabene (1986) is the most comprehensive
model of cognitive rehabilitation. This model provides the framework for clinicians to

develop an understanding about cognitive concepts, and allows for consistent and

89

efficient service delivery. The six-factor model provides an outline for treatment, a
framework for evaluation, treatment planning, and vocational counseling. In addition, it
is an educational tool for professionals, families, and clients, and provides a means for
quantifying evaluation of its effectiveness, and a basis for further empirical investigations
necessary in developing cognitive retraining models. This model was designed with a
goal of integrating the cognitive skill approach of Ben-Yishay (1987) with the concept of
head injury recovery provided by the Ranchos Los Amigos Scale.

The six-factor model focuses on six general cognitive areas applicable to the
understanding of persons with TBI recovery. The factors that compromise this model
were clinically determined and include the following: 1) arousal, attention, and
concentration, 2) memory, 3) sequencing, 4) visual spatial, 5) verbal abstract reasoning,
and 6) social/emotional. Application of this model includes treatment planning and
implementation of a rehabilitation program through task and job analysis. From a
treatment planning perspective, this model provides a framework for rehabilitation
professionals to organize the results of their evaluations in order to identify the client's
cognitive strengths and weaknesses. Once the evaluations are completed, professionals
can develop a treatment program geared towards addressing speciﬁc cognitive issues.
This model can foster consistent cognitive treatment across related as well as different
disciplines. In the case of task analysis, both cognitive and vocational functioning can be
analyzed in terms of skills required within a given cognitive area. Sachs et al., (1986)
stated that with this information, certain tasks that are suitable can be selected for each
individual in developing a specific cognitive area (s). In addition, the authors stated that

for vocational applications, this strategy can be used to retrain skills necessary for

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returning an individual to his or her previous job, or to recommend a different ﬁeld of
work.

Levin (1991) stated that a model of cognitive rehabilitation should generate
prescriptive evaluation information, assure ﬂexibility, and provide for individualization
of services based on the individual cognitive strengths and deﬁcits. In addition, the
model should generate quantifiable data for program evaluation and demonstrate
ecological validity by providing for generalization of skills to everyday settings. Bracy
(1994) posited that other important aspects of cognitive rehabilitation should include
clear, accurate, immediate feedback, and the careful selection of the complexity of
rehabilitation tasks that are at the borderline between current ability and the next highest
level of ability, and the consideration of different levels of functioning in different
cognitive areas (e.g., attention, memory, sensory).

Concerns Pertaining to Cognitive Rehabilitation as an Intervention Strategy

Cognitive rehabilitation as a discipline did not become popular until the 1980's.
Since the evolution of cognitive rehabilitation, considerable controversy has existed
regarding the usefulness and appropriateness of such programs. Controversial issues
have included arguments pertaining to the ability to effect change in a neurologically
stable individual, and the use of computers in the field of cognitive rehabilitation (Berrol,
1990). Other issues of concern pertain to the qualification of rehabilitation practitioners,
exclusion of neuropsychologists for treatment planning and monitoring of cognitive
rehabilitation, access to treatment, limited or no vocational goal formation, overlooking

causes and severity of brain injury, poorly developed treatment plans, poorly developed

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software, use of standardized psychological tests as training exercises, and cognitive
rehabilitation software that is not normed.
Service Delivery

It has always been stated that an important factor in cognitive rehabilitation is the
timing of the intervention. Some experts have suggested that many cognitive
rehabilitation programs enroll persons with TBI either too early after the injury or in
some cases too late. As such, these individuals may not beneﬁt from the intervention
because they are not prepared emotionally, behaviorally, or cognitively. Larkin (1992)
stated that many cognitive rehabilitation professionals understand that the behavioral
sequelae must be addressed prior to the initiation of cognitive rehabilitation if effective
learning is to occur.
Generalizability

A signiﬁcant factor in the use of cognitive rehabilitation is to help individuals
with TBI return to independence. As such, it is important for this intervention to be
generalizable across settings. Generalizability refers to the ability to apply a strategy
learned in cognitive rehabilitation to a novel situation, while transfer of learning suggest
the ability to take a speciﬁc learned skill that pertain to a certain job or an activity of
daily living and utilize it in different setting (Ryan, Sautter, Capps, Meneese, 1992;
Wehman et al., 1989). However, Fujii (1996) stated that cognitive rehabilitation as an
intervention lacks generalization beyond treatment sessions and therefore offers limited
beneﬁt to clients. Butler and Namerow (1988) argue that research on functional recovery
after TBI and the validity of cognitive rehabilitation shows that cognitive rehabilitation

intervention does not reliably improve treatment outcomes or hasten spontaneous

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recovery. In addition, some experts have suggested that cognitive rehabilitation tends to
focus on developing certain abilities that may not be useful in everyday settings (Parente
& Anderson-Parente, 1989). However, in response to such criticism, Butler and
Namerow (1988) stated that cognitive rehabilitation of individuals with TBI should focus
on skill acquisition training (SAT), a program which focuses on remediation of deﬁcits in
the areas of activities of daily living, social conversation skills, and vocational
performance.
Usefulness of Cognitive Rehabilitation

Over the last 25 years, the ﬁeld of brain injury rehabilitation has witnessed a rapid
expansion of rehabilitation facilities and programs. Many clinicians have commented
that, “the science of TBI rehabilitation has failed to maintain pace with the industry of
TBI rehabilitation” (p. 384) since the interest in developing cognitive rehabilitation
programs has not been matched by new scientiﬁc insights about how to restore, reverse,
or significantly improve deficits resulting from TBI (Prigatano, 1987; Putnam & Adams,
1992). When persons with TBI who are receiving cognitive rehabilitation intervention
make functional gains, it is often unclear just how these improvements were realized.
Spontaneous recovery may play a role or improvements could be the result of cognitive,
physical, or behavioral interventions. Despite the ever growing amount of literature on
cognitive rehabilitation techniques, there is little research on its efﬁcacy (Fujii, 1996).
However, the demand for evidence demonstrating the effectiveness of cognitive
rehabilitation programs has increased, primarily as a result of economic pressures on the
health care system. As a result of these economic issues, there is an increasing need to

show that these programs produce positive changes in persons with TBI level of

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functioning with the lowest possible costs associated with these changes (Diller, 1992;
Putnam & Adams, 1992).

The efﬁcacy of cognitive rehabilitation programs has fueled a debate as a result of
a lack of research on the usefulness of such programs. For example, the issues that
cognitive rehabilitation techniques or strategies are not adequately rooted in theory are
commonly debated. Proponents of this argument stress the need for research to validate
the efﬁcacy of cognitive rehabilitation and to develop an understanding of why some
treatments work and why others fail. Others have argued that theory is less important
than results in cognitive rehabilitation. They assert that if an individual with a TBI can
use a strategy, then it is effective. The question here is whether or not individuals with
TBI improve in the areas of memory, attention, and socio-behavioral areas as well as in
vocational outcomes. If so, why worry about theory? In addition to this issue, some
therapists question the usefulness of rehabilitation in general and are unconvinced that
cognitive rehabilitation can be an objectively measurable form of treatment. Critics of
cognitive rehabilitation have claimed that this type of treatment can produce no more
than practice effects rather than a genuine increase in cognitive functioning. As such, the
validity and efﬁcacy of cognitive rehabilitation has been questioned (Rattok et al., 1992).

In order to demonstrate the usefulness of rehabilitation for persons with TBI,
appropriate questions must be asked intelligently in well designed research programs.
However, given a number of controversial issues involved in research studies with
persons with TBI, efficacy studies of cognitive rehabilitation programs are limited or
generally unavailable. Published studies in journals that have evaluated the effectiveness

of speciﬁc cognitive rehabilitation programs are sparse, and of those studies that exist,

94

randomized, controlled trials of a speciﬁc treatment are practically non-existent (Hanlon
et al., 1992). Thus, it is difficult to determine if individuals with TBI beneﬁt from
cognitive rehabilitation, especially when signiﬁcant changes in the quality of life are
considered. One of the reasons there is a lack of studies on efﬁcacy of cognitive
rehabilitation interventions or programs include ethical concerns regarding withholding a
treatment program and the problem of confounding variables including heterogeneity of
the TBI population and spontaneous recovery. The most signiﬁcant problem that
presents a barrier to research in the ﬁeld of cognitive rehabilitation is the ethical issue
associated with not providing rehabilitation to a group just so rehabilitation versus non-
rehabilitation groups can be compared. Clearly, there will be evidence of deficiencies if
rehabilitation is not provided to survivors of TBI (Wilson, 1993).
Presently, it is possible to evaluate the effectiveness of some treatment programs.

In addition, it is possible to advocate general principles to be applied in all rehabilitation
programs. A major problem in demonstrating efﬁcacy is not being able to determine or
predict which individuals will respond to a speciﬁc intervention or program. This
inability to predict has been attributed to a lack of a general theory of cognitive
rehabilitation/remediation. Therefore, there is a lack of knowledge in identifying relevant
factors for predicting responsiveness. The limited prediction and outcome studies that
have been carried out have lacked speciﬁc ﬁndings. The only general ﬁnding across
studies has been that individuals with TBI who have higher functioning respond better to
cognitive rehabilitation interventions than individuals with lower functioning (Fujii,

1996).

95

Given the research dilemmas, Meta Analysis research design can effectively
address some of the aforementioned concerns. Meta Analysis is used to summarize
research, by combining the primary statistics from single studies and provide a common
statistics to describe and summarize the results of research reports. As Wachter & Straf
(1990) assert, Meta Analysis can and often does provide more rigorous reviews of
research than conventional techniques.

Although cognitive rehabilitation as a field has progressed, the efficacy of these
interventions is not at the stage where treatment programs can be prescribed with any
degree of certainty. The main reason for this is the heterogeneity that exists among
persons with TBI. Different types and severity of brain damage affect cognitive
functioning in different ways. Additionally, physical, motor, sensory, emotional, and
behavioral deﬁcits common in individuals with TBI need to be taken into consideration
when developing rehabilitation interventions. Each individual will have different needs,
circumstance, and requirements that will allow them to cope successfully in a home
and/or community environment. Given the breadth and diversity of type of injuries,
severity, pre-morbid and environmental factors amongst individuals with TBI receiving
rehabilitation, it is difficult to evaluate cognitive rehabilitation programs using traditional
research designs. Thus, the need to use new procedures for evaluating efﬁcacy is needed
(Wilson, 1993).

Despite limited research in the field, the overall efﬁcacy of cognitive
rehabilitation has been demonstrated in many studies. Overall, studies of specific
interventions with speciﬁc types of individuals or geared towards a speciﬁc deﬁcit have

consistently shown that individuals with TBI can improve their performance on tasks

96

with practice. Over time these improvements have had an effect on IQ scores and the
ability of individuals with TBI to adapt. Most practitioners agree that cognitive
rehabilitation as an intervention strategy helps individuals with TBI to use residual
cognitive and perceptual skills more effectively rather than restoring or retraining lost

functions (Prigatano, 1987).

97

CHAPTER III
DESIGN AND METHODOLOGY

This dissertation will scientiﬁcally review the research studies that have
investigated the efﬁcacy of cognitive rehabilitation intervention on subsequent outcomes
for persons with traumatic brain injury. Meta-analysis will be the method employed to
statistically integrate the findings, as well as compare and draw conclusions based upon
available evidence. The review of this compilation of studies should allow the
investigator to determine the effectiveness of cognitive rehabilitation on the remediation
of memory, attention, and socio-behavioral deﬁcits; the impact of cognitive rehabilitation
on vocational outcomes; as well as characteristics that contribute to effective
interventions. In addition, this analysis will allow the investigator to report the statistical
analysis of the results and to differentiate between characteristics that lead to successful
and non successful outcomes. Once the analysis is completed the conclusions that are
drawn will be based on the patterns associated with the statistical results of the research
literature on cognitive rehabilitation interventions with individuals with TBI.

A comprehensive review of the literature on the remediation of memory,
attention, and socio-behavioral deﬁcits following cognitive rehabilitation was undertaken.
This chapter also describes the criteria used in selecting the studies of cognitive
rehabilitation intervention on subsequent vocational outcomes and the procedure used in
selecting existing studies for this investigation are discussed. Additionally, the method of
coding is reviewed and a description of each variable on the coding instrument is
provided as well as a detailed description of the procedures used in the analysis and

synthesis of the data.

98

The study entails a comprehensive examination of studies that have applied
cognitive rehabilitation/remediation services to persons with TBI and reported on
subsequent outcomes. Meta-analysis procedures will be used to test the efficacy of
cognitive rehabilitation strategies. Meta-analysis refers to the application of quantitative
methods to the problem of combining results from different analytical studies. Meta-
analysis is not a statistical method, but rather an orientation toward research synthesis
that uses many techniques of measurement and data analysis (Wachter & Straf, 1990).

As previously stated, traumatic brain injury affects an individual’s physical,
cognitive and psychosocial functioning. As such, the vast majority of persons with TBI
experience deﬁcits in physical, memory, attention, and socio-behavioral functioning.
Some studies have shown that cognitive rehabilitation following traumatic brain injury
has little or no effect on memory, attention, and socio-behavioral/self—regulation deﬁcits.
On the other hand, studies have shown cognitive rehabilitation to be signiﬁcantly
correlated with improving memory, attention, and socio-behavioral deﬁcits following
traumatic brain injury. A meta-analytic review is warranted to help to resolve the
ambiguity resulting from contradictory research ﬁndings.

The ﬁrst reason the question is unresolved is that there have been many studies
that did not control for the severity of injury. For example, it appears that the more
severe the level of impairment the less likely that vocational outcomes are positive.
Additionally, assessing cognitive rehabilitation is complicated by spontaneous recovery.
It appears that the earlier the intervention following traumatic brain injury, the more

clients improve as a result of physical and physiological recovery in the brain itself.

99

Additionally, there is a difficulty in assimilating results from the many studies using

small group and single-subject designs.

As such, it appears appropriate to apply the techniques of meta-analysis to this

literature in order to address the following questions:

(1)

(2)

(3)

(4)

How effective is cognitive rehabilitation intervention on the remediation
of memory deﬁcits following traumatic brain injury?

How effective is cognitive rehabilitation intervention on the remediation
of attention deficits following traumatic brain injury?

How effective is cognitive rehabilitation intervention on the remediation
of socio-behavioral/self-regulation deﬁcits following traumatic brain
injury?

What are the relationships between factors such as age at time of accident,
years of education, socio economic status, severity of injury, and ethnic
background of individuals on subsequent vocational outcomes following
cognitive rehabilitation intervention with persons with traumatic brain
injury?

Collecting the Data

This study is primarily a literature review on the effectiveness of cognitive

rehabilitation as an intervention strategy in the remediation of memory, attention, and

socio-behavioral deficits following traumatic brain injury. Computer retrieval searches

were carried out in the following data bases: PsycLIT which is compiled from material

published in Psychological Abstracts and the PsycINFO data base (produced by the

American Psychological Association), Educational Resources Information Center

100

(ERIC), Dissertation Abstracts, and the National Library of Medicine. The literature
review will primarily include journals of research and theory in rehabilitation
psychology, rehabilitation counseling, head trauma, neuropsychology, and cognitive
rehabilitation. Aside from the literature providing historical and theoretical perspective,
the literature focuses primarily on the time period from 1980 to 2003. The search yielded
appropriate articles from the following journals: American Journal of Occupational
marapy, Archives of Clinical Neuropsychology, Archives of Physical Medicine and

Rehabilitation, Brain Injury, Canadian Journal of Rehabilitation, Canadian Psychology,

 

Clinical Psychology Review, Clinical Neuropsychologiat, Cognitive Rehabilitation,
International Journal of Rehabilitation, Journal of Applied Rehabilitation Counseling,
Journal of Clinicﬂeuropsychology, Journal of Clinical and Experimental
Neuropsychology. Journal of Consulting and ClinicaLPsychologv, Journzaat:
Intematioaal Neuropsychology and Sociology, Journal of Learning Disabilities, Journal
of Neurology, Journal of Neurological Rehabilitation, The Journal of Rehabilitation,
Journal of Head Tram Rehabilitation, Journal of Neurology. Neurosurgery, an_d
Psychiatry, Memory, Neurosurgery, Neuropsychological Rehabilitation.
Neuropsycholggja, Rehabilitation Counseling Bulletin, Seminars in Neurology,
Rehabilitﬁation Psychology, and Psychiatg.

In order to conduct the search, the following descriptor terms were used:

"cognitive rehabilitation," "brain injury, traumatic brain injury and vocational

outcomes, cognitive rehabilitation with brain injured," and "brain injury rehabilitation,"

"head injured," "employment potential following brain injury, traumatic brain injury,"

"cognitive remediation, cognitive rehabilitation strategies," and “meta analysis.”

101

The search produced a reference list of potential studies to be included in the
sample. Many studies could not be retrieved locally, and attempts were made to locate
studies through inter-loan library and through the National Clearing House. Once the
study was located, each abstract was read to determine whether the study could be
included in the pool of potential studies. Potential studies were dismissed if (1) no
statistics were reported, (2) reported statistics were not sufﬁcient for calculating or
approximating an effect size, (3) cognitive rehabilitation was not deﬁned appropriately,
(4) and outcomes were not clearly stated. Studies that met the criteria became the data set
for the analysis and synthesis portion of the study.

Criteria for Inclusion /Population

The article review format was constructed by the investigator. A complete review
of the literature was conducted in order to acquire all published and unpublished studies
that met the following criteria:

(1) The study was published in English

(2) Cognitive rehabilitation was operationally deﬁned in a way that is

consistent with the deﬁnition formulated in the present study.

(3) The study included individuals with an acquired TBI.

(4) The participants in the study were at least sixteen years of age.

(5) The study reported quantitative analysis from which a correlation

coefﬁcient could be obtained.

(6) The study was reported in the period 1980 to 2003, as this appears to be a

signiﬁcant period in which cognitive rehabilitation as an intervention

strategy was utilized within brain injury treatment facilities.

102

Coding Instrument

Once all appropriate studies were identiﬁed and collected a coding instrument
was developed so that effect sizes and study characteristics could be recorded. Study
characteristics were categorized as substantive which includes features that are specific
to the problem studied (e.g., type of associated variable), and methodological which are
general features such as year published, publication form, or sample size (Glass, McGaw,
Smith, 1981). The researcher completed the coding as studies were gathered. According
to Glass et a1. (1981) "the principal source of measurement unreliability in meta-analysis
arises from different readers (coders) not seeing or judging characteristics of a study in
the same way" (p. 75). To test for coder reliability, a second coder was trained and that
individual coded three studies.

Variables that were used in the coding instrument are described in the following
section:

Study Number: An identiﬁcation number was assigned to each study in the order
it was coded, starting with Number 1.

Author(s): The principal investigator(s) of the study.

Publication Year: The year noted on the manuscript was recorded. For studies
that appear in multiple forms, the year of the most extensive report was used.

Publication Form: The study was classiﬁed according to the form in which it
was published: (a) journal article, (2) book, (3) dissertation based publication, (4)
unpublished dissertation.

Sample Size: The sample size was recorded

103

Mean Age of Subjects: The mean chronological age of the study participants was
recorded as (1) reported in the study, (2) approximated from data in the study, or (3) not
obtainable.

Mean Educational Achievement Level of Subjects: The mean number of years
of formal education of the study participants was recorded as (1) reported in study, (2)
approximated from data in the study, or (3) not obtainable.

Median Socio-economic Status of Subjects: Median socio-economic status of
study participants was recorded as (1) low SES, (2) middle SES, or (3) high SES. In
those cases where actual mean income was provided, the following categories were used:
low (below 12,000), middle ($12,000 - $40,000), and high (higher than $40,000).
Median socio-economic status of subjects was recorded as (1) reported in the study, (2)
approximated from data in the study, (3) not obtainable.

Gender of Subjects: The percent of male and female participants in the sample
was recorded as (1) reported in the study, (2) approximated from data in the study, (3) not
obtainable.

Cultural/Racial Mix: The percent of African Americans, Asian Americans,
Hispanics, Native Americans, and White Americans in the sample was recorded as (1)
reported in the study, (2) approximated from data in the study, (3) not obtainable.

Severity of Injury: The number of participants with mild, moderate or severe
brain injury was recorded as (1) reported in the study, (2) approximated from data in the
study, (3) not obtainable.

Associated Variable: This category was designed to identify variables associated

with cognitive rehabilitation intervention of persons with TBI. The categories for coding

104

these variables were determined from reading the journal articles as well as books on
cognitive rehabilitation with persons with TBI.

Glass et al. (1981) posited that coding classifications should not be narrowly
speciﬁed. The authors asserted that "generalizations will necessarily entail ignoring
some distinctions that can be made among studies. Good generalizations will be arrived
at by ignoring only those distinctions that make no important difference" (p. 23). In
response, Hedges (1986) questioned the use of broad coding classiﬁcations. He
suggested that this approach might obscure "important differences among the narrower
constructs subsumed therein" (p. 358). If broader constructs are to be used, Hedges
(1986) posited that they should be used in the narrative summary of the review, but
narrower constructs should be used in the statistical analysis of the data and report of the
ﬁndings. The use of broad constructs has been a criticism of meta-analytic reviews
(Eysenck, 1984; Gallo, 1978; Presby, 1978). As such, this study employed a narrower
construct for the data analysis. A narrower construct according to Hedges (1986)
"permits the reviewer to examine variations in the pattern of results as a function of
construct deﬁnition" (p. 359).

Description of Associated Variable: A description of the associated variable and
any relevant information obtained in the study was recorded.

Study Qualitﬁyz A numerical rating of the study quality will be assigned to each
study on the basis of the following criteria (adapted from Hembree, 1984).

a) Problem Identiﬁcation: clear hypotheses or research questions (3), no

hypotheses or research questions but clear statement of purpose (2), none

of the aforementioned (1).

105

b) Population Description: description of demographic items, i.e., age,
gender, race, educational level, socio-economic status, employment level,
and marital status. Six to seven demographic items obtainable (3), three to
ﬁve items obtainable (2), less than three demographic items obtainable (1).

c) gimpling Procedure: random (3), partially random (2), non-random (1)

(1) Conclusions: appropriate and tied to hypothesis, research questions, or
purpose (3); appropriate, but with digressions (2); inappropriate (1).

e) Data Analysis: appropriate methods with full reporting of results (3),
appropriate methods with partial reporting or some data missing (2),
inappropriate methods, mistakes, or much data missing (1).

Each criterion was evaluated on a scale from 1-3 (where 1 is low and 3 is high).

Effect Size Determination: Meta analysis is based on the effective size (ES)

statistics, which allows for the quantiﬁcation and standardization of study findings.
Within this investigation, the ES statistics will be deﬁned in two ways: (1) reﬂecting
differences in the nature of the comparison group, or (2) reﬂecting differences on some
pre post test score measurement (Wolf, 1986; Glass, 1981). Those studies where the TBI
group is compared with a non-disabled (i.e., average IQ) group (N), the ES will be

defined as:

E5 = M tbi - M ntbi

 

Sd ntbi

where Mtbi = the average performance level for the traumatic brain injured group,
Mntbi = the average performance level for the non-disabled comparison group, and

Sdntbi = standard deviation for the nondisabled comparison group.

106

Those studies where there is a comparison of a pre-test and a post-test measure,
the ES was deﬁned as:

ES = X post - X pre

 

Sd pre

Where X pre = average performance level for the untrained condition,
X post = average performance level for the training condition, and

Sd pre = standard deviation for the untrained condition.

The study within the total pool of studies gives their statistical results as one of
these four types of statistics: t-scores, f-scores, r—scores, and ES-scores. The coding
process will be used to transform each statistical result of each study into a common
metric; the ES score ((1 score). Once all scores had been transformed into the ES score,
statistical procedure of computing statistical analysis on a t distribution was completed,
i.e., the computation of a mean ES score, Standard Deviation, etc. The advantage of a
Meta analysis is the ﬂexibility to aggregate the ES scores by numerous variables and
pertinent categories within the variables.

Statistical Conversions

Meta Analysis procedures outlined by Glass (1981) and Wolf (1986) provide

guidelines for converting various test statistics to the d score (statistical reference to ES

statistics) are as follows:

 

 

Statistics to be Converted Formula used for Conversion
t-score 2t
ES:
(if

107

f-score 2 F

ES:
df
r-score 2r
ES:
1 — (r )

The score from each study was converted to the common statistics, the (1 score ((1)
or Effect Size (ES). A typical statistical analysis was used to compute effect size scores
into sample distributions, mean score, standard deviations, etc., which determined if the
population mean, differed signiﬁcantly from zero; the inference is the mean score of ES
equals 0 (ES=0), which implies that interventions are not successful with individuals
with TBI.

The inference in the alternative hypothesis is if the mean score of ES is greater
than zero on the positive end (falling within the critical value) of the scale then cognitive
rehabilitation intervention is successful (had signiﬁcant effects) with individuals with
TBI. However, if the mean score of BS is greater than 0 on the negative end of the scale
then cognitive rehabilitation as an intervention on average was not effective.

The selection of a particular probability value is purely an arbitrary one
(Blommers & Forsyth, 1977). This investigation will use a .01 alpha level (a one in a
hundred), as a conservative level of signiﬁcance and to reduce the possibility of Type I
error (rejecting Ho when it is actually true).

Individual ES scores were calculated for each major variable in each study and
then aggregated to investigate the area(s) of interest. The variables that were selected to

report statistical results are: remediation of attention after cognitive rehabilitation,

108

remediation of memory after cognitive rehabilitation, and remediation of socio-
behavioral deﬁcits after cognitive rehabilitation. In addition, there were descriptive
results reported upon several other variables. They are: source of publication, studies by
year, demographic data on subjects (number in treatment group, number in control group,
gender, and age), ethnic/racial background of subjects, socioeconomic status of subjects,
years of education, and severity of injury. The comparisons were made between
cognitive rehabilitation interventions study characteristics that allow for final conclusions
to be drawn which are statistically based on the patterns associated with cognitive
rehabilitation, as a result of a review and analysis of the studies included in this

investigation.

109

CHAPTER IV
INVESTIGATION AND RESULTS
The purpose of this research is to determine the effectiveness of cognitive
rehabilitation interventions in enhancing memory, attention, and socio-behavioral deﬁcits
of individuals with TBI. The aim is to assimilate and synthesize the literature regarding
the impact of cognitive rehabilitation on vocational outcomes. The results of this
investigation for cognitive rehabilitation interventions on memory will be presented first.
This will be followed by results for cognitive rehabilitation interventions on attention,
and ﬁnally cognitive rehabilitation interventions on socio-behavioral deﬁcits. In each
section, the descriptive results of the investigation will be presented ﬁrst for each area,
followed by the statistical results.

To assess inter-rater reliability of the coding system, five of the cognitive
rehabilitation studies on the remediation of memory impairment following TBI, four of the
cognitive rehabilitation studies on remediation of attention deficits following TBI, and
three of the cognitive rehabilitation studies on the remediation of socio-behavioral deﬁcits
following TBI were randomly selected to be coded by a total of three other individuals
deemed knowledgeable in brain injury. Coders received a copy of the code sheet which
included all the operational deﬁnitions used for the code sheet and their allocation of the
randomly selected studies.

The three coders’ rating sheets were compared with the investigator code sheet.

An agreement was counted when coders selected the same category for an item on the
coding sheet (severity of injury) or when coders recorded the same information for an

item on the coding sheet (number of subjects, etc.). Total agreement ranged from 86% to

110

97% with an average of 92%. Inter-rater agreement on the ES score calculations was
100%.

As a result of the literature search, 465 published articles were located on
cognitive rehabilitation interventions with persons with TBI. The abstracts and in many
cases the complete articles were reviewed in order to determine which articles would be
suitable for inclusion into the study. Each article was placed into 1 of 3 categories,
reﬂecting its primary area of intervention: remediation of memory deﬁcits, remediation
of attention deﬁcits, and remediation of socio-behavioral deﬁcits. Following that, each
article was abstracted according to specific criteria: subject characteristics (age, gender,
education, severity of injury, time post injury, and inclusion criteria); treatment
characteristics (treatment setting, targeted deﬁcit, and nature of treatment); and statistical
analysis performed.

Of these, 248 studies were eliminated from the data analysis. N inety-two studies
were excluded because the subjects had diagnoses primarily other than TBI; 86 studies
did not report statistics that were sufficient for calculating or meaningfully approximating
an effect size (for example, only means without standard deviations or correlations were
reported); 39 studies did not include treatment and consisted of single trial, experimental
manipulations; and 31 studies were descriptive reports that did not contain any empirical
data. The remaining 217 studies contributed the data for this study.

Introduction to Cognitive Rehabilitation of Memory
Deﬁcits in Individuals with TBI
Studies of the remediation of memory deficits have addressed a range of memory-

related issues including general concerns (everyday memory problems, impaired

111

learning), speciﬁc memory problems (remembering names, dates, faces, etc.), the
capacity to effectively use compensatory aids (computers, memory books), and individual
subjective complaints. Interventions to address these problems have included use of
compensatory aids, as well as cognitive remediation programs to address the
aforementioned issues. The purpose of this section of the investigation was to collect and
evaluate the empirically based studies pertaining to cognitive remediation of memory
deﬁcits following TBI (n=120).

The descriptive results of this investigation for cognitive rehabilitation
interventions will be presented ﬁrst and are displayed in tables 1 through 5, followed by
the statistical results, which are presented in tables 6 through 13.

Cognitive Rehabilitation of Memory Deﬁcits in
Individuals with TBI Study Characteristics

This investigation reviewed 120 articles on the remediation of memory deficits in
individuals with TBI. One hundred and nine studies were published in journals, 7 were
published in books, and 4 were published as dissertations spanning the years 1980
through 2003. The studies had been published in cognitive rehabilitation journals,
traumatic brain injury and head injury journals, physical medicine and rehabilitation
journals, neurology journals, neuropsychological rehabilitation journals, cognitive
rehabilitation and brain injury rehabilitation books, and Dissertation Abstracts
International.

Table 1 shows sources of publication, which provides a frequency distribution of
the studies in cognitive rehabilitation of memory data collection as well as a calculation

of the percentage of the total studies contributed by each source.

112

Five major sources (n: 93) provided 76% of the total studies on cognitive
rehabilitation of memory impairments for this investigation. They were Journal of Head
Trauma Rehabilitation (n = 22, 19.17%), Cognitive Rehabilitation (n = 20, 16.67%),
Journal of Clinical Neuropsychology (n = 15, 12.50%), Brain Injury (n = 13, 10.83%),
and Neuropsychological Rehabilitation (n = 13, 10.83%). The remaining 24% of the
studies (11 = 27) were distributed across 13 other sources. Table 2 shows these five major
sources and their contributions for cognitive rehabilitation of memory impairments in

individuals with TBI.

113

Table 1: Cognitive Rehabilitation of Memory Deficits in Individuals with TBI:

Sources of Publication

 

 

 

Journal Title/Book Frequency % of Totals
American Journal of Occupational Therapy 5 4.17%
Applied Cognitive Psychology 2 1.77%
Archives of Physical Medicine and Rehabilitation 5 4.17%
Brain and Cognition 2 1.77%
Brain Injury 13 10.83%
British Journal of Clinical Psychology 1 0.83%
Canadian Journal of Rehabilitation 2 1.77%
Cognitive Rehabilitation 20 16.67%
Cognitive Retraining Using Microcomputers 1 0.83%
Disability Rehabilitation 2 1.77%
International Journal of Rehabilitation Research 3 2.50%
Journal of Applied Behavior Analyst 2 1.77%
Journal of Head Trauma Rehabilitation 22 18.33%
Journal of Clinical Neuropsychology 15 12.50%
Journal of Consulting and Clinical Psychology 4 3.33%
Journal of Clinical Experimental Neuropsychology 5 4.17%
Neuropsychologia 2 1.77%
Neuropsychological Rehabilitation 13 10.83%
The Behavior Therapist 1 0.83%
Totals 120 100.00%

 

114

Of the 120 studies, 56 (46.67%) were published during the period from 1980 to
1990, while the other 64 (53.33%) were published between 1991 and 2003. Table 2 and
3 shows the cognitive rehabilitation of memory impairment in individuals with TBI

studies by year.

 

 

 

 

 

 

 

Table 2: Cognitive Rehabilitation of Memory Deficits in Individuals with TBI:
Studies Per Year from 1980 to 1990
# Studies Year % of Total Studies
Per Year
2 1980 1.67%
1 1981 0.83%
2 1982 1.67%
2 1983 1.67%
5 1984 4.17%
4 1985 3.33%
7 1986 5.83%
8 1987 6.67%
7 1988 5.83%
10 1989 8.33%
8 1990 6.67%
56 46.67%
Table 3: Cognitive Rehabilitation of Memory Deﬁcits in Individuals with TBI:
Studies Per Year from 1991 to 2003
# Studies Year % of Total Studies
Per Year
3 1991 2.50%
2 1992 1.67%
5 1993 4.17%
8 1994 6.67%
6 1995 5.00%
10 1996 8.33%
1 l 1997 9.17%
2 1998 1.67%
7 1999 5.83%
5 2000 4.17%
1 2001 0.83%
3 2002 2.50%
__ 1 2003 0.83%
64 53.33%

 

115

Cognitive Rehabilitation of Memory Deﬁcits in
Individuals with TBI: Subject Characteristics

The 120 studies included a total of 3,840 individuals with TBI who received
cognitive rehabilitation intervention for memory deﬁcits. The number of individuals per
study ranged from 1 to 269, with an average 32 individuals per study for the experimental
and control groups. Table 4 displays cognitive rehabilitation of memory impairments
studies as reported by researchers of the subject demographic data.

Ninety-two of the 120 studies reported TBI individuals’ gender, with 76.36%
being males (11 = 2039) and 23.63% being females (11 = 631). Based on those studies that
report gender data (11 = 92) there was an average of 21 males with TBI and 8 females with
TBI in each study.

Age was reported in ninety- one percent of the studies (n=109). The mean
average age of individuals with TBI across all studies was 33.4 years (ages ranged from
18 to 56 years). The mean socioeconomic level was reported in only 21.6% of the studies
(n=21). In 26.66% of the studies (n=32), researchers described the cultural/racial mix of
the subjects. Among those studies 59.27% of the subjects were White (n=598), 25%
were African Americans (n=249), 10.51% were Latino (n=106), and 4.56% were reported
as other (n=46). Severity of injury was reported or approximated in 87.5% of the studies
(n=105), with 10.15% being reported as mild TBI (n=247), 35.43% being reported as
moderate TBI (n=862), and 54.42% being reported as severe TBI (n=1324). Table 5

shows the breakdown of the severity of TBI.

116

Table 4: Cognitive Rehabilitation of Memory Deficits in Individuals with TBI:
Demographic data on Subjects

 

 

 

 

 

Subject Category # Individuals % of Population
Sample # 3840 100
Experimental Subjects # 2433 , 63.36
Control Subjects # 1407 36.64
Table 5: Cognitive Rehabilitation of Memory Deﬁcits Severity of TBI Subjects
Severity of TBI Subjects # Individuals % of Population
Mild TBI 247 10.15%
Moderate TBI 862 35.43%
Severe TBI 1324 54.42%
Total 2433 100%

 

117

Cognitive Rehabilitation of Memory Deficits in
Individuals with TBI Statistical Results:
Acceptance or Rejection of the Hypothesis
The statistical results accepting or rejecting the hypothesis, i.e., that
cognitive rehabilitation intervention will be positively correlated with the remediation of
memory deﬁcits following traumatic brain injury was examined in this section.

A t-test was computed on the grand total of all BS scores, i.e., ﬁnding the total
number of all BS scores, and computing an average effect size, determining a standard
deviation, and calculating the t-test. Overall, the total score data set has a mean ES score
of 0.392 (n=1783) and a Sd of 1.869. This t-test statistics was: tdf1784=7.403, [p<.01],
which indicates that the results of cognitive rehabilitation intervention on memory
impairments following TBI are statistically signiﬁcant. Table 6 gives the statistical data
as reported by researchers for the remediation of memory studies:

The number of effect sizes per study ranged from 1 to 33, with an average number
of 8.09 effect size scores per study. Effect sizes ranged from 35 to -8.23457, with an
average effect size score of 0.392 (with a standard deviation of 1.869). Table 7 gives the
data on the effect size scores by category, number, and percent of the total as reported by
researchers in each study. Table 8 shows the types of statistics reported by researchers

and the average effect sizes on types of scores categories.

118

Table 6: Statistical Results on the Cognitive Remediation of Memory Deficits

 

following TBI

Average ES: 0.392
Number: 1783
Minimum Score: 35
Maximum Score: -8.23457
Sd: 1.869
t-tests: 8.263
Outcome: *

 

* p<.01 is significant

119

Table 7: Effect Size Scores by Category, Number, and Percent of the Total

 

 

 

Category Number of Scores % of the Total

t-score 1259 70.61%
f—score 444 24.91%
r-score 63 3.51%
d-score (effect size) 17 0.95%
Total Scores 1783

 

Note: average number of scores per remediation of memory study (based on 120
studies) 8.09

Range of effect sizes: 35 to -8.23457
Mean average of effect sizes across all memory studies: 0.392

Standard deviation: 1.864

120

Table 8: Cognitive Remediation of Memory Deficits in Individuals with TBI: Type
of Score Categories

 

Category Frequency Mean ES SD t-test Signiﬁcance
t-score 1259 0.248 2.326 3.713 *
f-score 444 0.659 0.425 23.778 *
r-score 63 0.945 1.202 5.469 *
d-score

(Effect Size) 17 1.548 0.869 7.733 *
Grand Total 1783 0.392 1.864 8.2633 *

 

*p<.01 is signiﬁcant

It was noted that some of the effect size scores were very extreme. The researcher
removed the extreme 1% of scores and recalculated the effect size to prevent those score
from skewing the results (Babbie, 2001). As such, the next step was to sort all of the
cognitive remediation of memory impairment after a TBI ES scores according to their
absolute values. The primary reason for this was that statistically, these top 1% scores
were greater than three (3) standard deviations from the mean. Therefore, their removal
as outliers seemed to be appropriate in this case. In addition, in order to ensure the
accuracy of the ﬁnal results after creating this new set of data, referred to as the adjusted
scores data set, the results will comprise both sets of data. The process of selecting the
outlier scores, their subsequent removal and the creation of the adjusted scores are as
follows: (1) calculate 1% of the total scores which equals 14, (2) make a list and convert
all scores to absolute scores, (3) select the most extreme scores, which equals 14, and (4)
remove the 1% extreme scores from the total score set, which becomes the adjusted score

set which to compare the patterns of statistical results too that of the total score set. Table

121

9 shows the fourteen most extreme remediation of memory ES scores, and their absolute
values and category of score.

Upon removal of these extreme 1% ES scores, the adjusted ES scores were
examined. The only adjusted type of scores category affected by removing these extreme
scores was the t-score category, which was very minimal. The data on all of the other
categories remained the same. As a result, the mean effect size of the t-score category
decreased from 0.248 to 0.126. The number of scores decreased from 1259 to 1245 (14
less), and the standard deviation decreased from 2.326 to 1.274. The t-statistic changed
slightly from tdf1259=3.713, [p<.01], to a t-value for the adjusted data of tdf1245=3.215,
[p<.01], which is still signiﬁcant.

The t-test based on the adjusted score data resulted in a mean ES score of 0.293, a
Sd of 1.164, and a t-statistic of tdf1767=9.752, [p<.01], an increase that is signiﬁcant.
The ﬁnal comparison of the total score group with the adjusted score group on t-statistics
indicates the t-test value of tdf1783=8.263, [p<.01], compared to tdf1767=9.752, [p<.01].
This evidence is signiﬁcant in that it reveals the impact that extreme scores can have on
the central tendency of the remediation of memory impairment data. The t-score is the
largest category of types of BS scores; yet it appears that the reduction of these heavily
weighted scores did not affect the overall results. Table 10 shows the statistical categories
as reported by researchers, the average effect sizes, and the categories for the adjusted
score set. Table 11 shows the comparison of the type of statistics reported by researchers
and the average effect sizes of the scores reported by researchers and the adjusted scores.

Table 12 shows the severity of injury data reported by researchers, the mean effect sizes,

122

and the two signiﬁcant categories and table 13 shows the severity of injury data, the

average effect sizes, and two significant categories for the adjusted score set.

123

Table 9:

The Fourteen most Extreme ES Scores, Absolute Scores and Score Type

 

 

Mean Sd from Mean Type
ES Score of Score
35 18.807 t-score
34.444 18.525 t-score
15.228 7.596 t-score
12 5.889 t-score
11.135 5.527 t-score
1 1 5.487 t-score
8.076 4.023 t-score
7.999 4.012 t-score
6.87 3.672 t-score
6.01 3.104 t-score
6.322 3.051 t-score
6.058 3.120 t-score
5.971 3.015 t-score
-8.234 3.794 t-score

 

124

Table 10:

Cognitive Remediation of Memory Deficits following TBI with Fourteen
Outlying Scores Removed

 

 

Category Frequency Mean ES Sd t-test Signiﬁcant
t-score 1244 0.114 1.164 3.215 "‘
f—score 443 0.571 0.498 22.263 *
r-score 63 0.879 1.361 6.479 *
d-score

(Effect Size) 17 1.581 0.798 8.721 *
Grand Total 1767 0.293 1.164 9.752 *

 

*p<.01 is signiﬁcant

 

 

Table 11: Comparison of Total Scores and Adjusted Scores
Total Scores Adjusted Scores (extreme 1% scores)

Average ES: 0.392 0.293
Number: 1783 1767

Minimum: -8.234 -5.373

Maximum: 35 5.897
Standard

Deviation: 1.869 1 . 164
t-tests: 8.263 9.752

Outcome: significant results

*significant results*

 

*p<.01 is significant

125

Table 12: Severity of Injury on Total Score Set

 

 

 

 

 

Category Frequency Mean ES Sd t-test Signiﬁcant
Severe TBI 0.408 1.826 6.535 *
Moderate TBI 0.403 2.157 5.520 *
Mild TBI -0.027 0.745 -0.289

*p<.01 is signiﬁcant

Table 13: Severity of Injury on Adjusted Score Set

Category Frequency Mean ES sd t-test Significant
Severe TBI 0.322 1.063 8.825 *
Moderate TBI 0.307 1.278 7.039 *
Mild TBI -0.027 0.745 -0.289

 

*p<.01 is signiﬁcant

126

Introduction to Cognitive Rehabilitation of Attention
Deﬁcits in Individuals with TBI

Remediation of attention deficits have for the most part relied on drill and
practice, with exercises created to address speciﬁc aspects of attention (e. g., processing
speed, divided attention, focused attention). Most of the literature that reports this type of
intervention have used stimulus-response parameters, which required participants to
identify and select among relevant auditory or visual stimuli, and often used speeded
stimulus presentations (Cicerone, et al., 2000). The goal of these interventions is to
restore basic attention abilities through repeated practice. Many of the studies reviewed
have relied on psychometric measures to assess improvements in attention attributable to
treatment.

The purpose of this section of the investigation was to collect and evaluate the
empirically based studies pertaining to cognitive remediation of attention deﬁcits
following TBI (n=67).

The results of this section will be presented as it was for remediation of memory
deficits, i.e., descriptive results of cognitive rehabilitation of attention deficits following
TBI which are shown in tables 14 through 19, followed by statistical results which are
displayed in tables 20 through 27.

Cognitive Rehabilitation of Attention Deficits Following TBI:
Study Characteristics
Sixty-seven studies were examined in this area, with all 67 published in journals spanning

the years 1980 through 2003. The 67 studies had been published in journals of

127

psychology, brain injury, cognitive rehabilitation as well as some occupational therapy
journals.

Table 14 shows the sources of publication and provides a frequency distribution
of the studies published in this area. Top four major sources (n: 47) provided 70.15% of
the total studies on cognitive rehabilitation of attention deﬁcits of this investigation. They
were Journal of Head Trauma Rehabilitation (n = 16, 23.88%), Cognitive Rehabilitation
(n = 15, 22.39%), Brain Injury (n=10, 14.93%), and Neuropsychological Rehabilitation
(n = 6, 8.96%). The remaining 29.85% of the studies (n = 20) were distributed across the
6 other sources.

Of the 67 studies, 29 (43.28%) were published during the period from 1980 to
1990, while the other 38 (56.72%) were published between 1991 and 2003. Table 15 and
16 shows the cognitive rehabilitation of attention deficits in individuals with TBI studies

by year.

128

Table 14: Cognitive Rehabilitation of Attention Deﬁcits in Individuals with TBI:
Sources of Publication

 

 

 

Journal Title Frequency % of Totals
American Journal of Occupational Therapy 2 2.99%
Archives of Clinical Neuropsychology 2 2.99%
Archives of Physical Medicine and Rehabilitation 1 1.49%
Brain Injury 10 14.93%
Canadian Journal of Rehabilitation 2 2.99%
Cognitive Rehabilitation 15 22.39%
Canadian Psychology 2 2.99%
International Journal of Rehabilitation Research 2 2.99%
Journal of Head Trauma Rehabilitation 16 23.88%
Journal of Clinical Neuropsychology 3 4.48%
Journal of Consulting and Clinical Psychology 1 1.49%
Journal of Clinical Experimental Neuropsychology 2 2.99%
Joumal of Neurological Rehabilitation 3 4.48%
Neuropsychological Rehabilitation 6 8.96%
Totals 67 100.00%

 

129

Table 15: Cognitive Rehabilitation of Attention Deficits in Individuals with TBI:
Studies Per Year from 1980 to 1990

 

 

 

 

 

 

 

# Studies Year % of Total Studies
Per Year

1 1980 1.49%
1 1981 1.49%
2 1982 2.99%
2 1983 2.99%
4 1984 5.97%
7 1985 10.45%
2 1986 2.99%
3 1987 4.48%
1 1988 1.49%
3 1989 4.48%
3 1990 4.48%
29 43.28%

Table 16: Cognitive Rehabilitation of Attention Deficits in Individuals with TBI:

Studies Per Year from 1991 to 2003
# Studies Year % of Total Studies
Per Year

2 1991 2.99%
l 1992 1.49%
6 1993 8.96%
3 1994 4.48%
4 1995 5.97%
7 1996 10.45%
3 1997 4.48%
2 1998 2.99%
4 1999 5.97 %
3 2000 4.48%
0 2001 0.00%
2 2002 2.99%
l 2003 1.49%
38 56.72%

 

130

Cognitive Rehabilitation of Attention Deficits in Individuals with TBI:
Subjects Characteristics

The 67 studies of cognitive rehabilitation intervention for attention deﬁcits
included 2,211 individuals with TBI. The number of individuals per study ranged from 3
to 108, with an average of 33 individuals per study. Table 17 displays the subject
demographic data for studies of cognitive rehabilitation of attention deficits.

Research studies reported the gender of individuals with TBI receiving cognitive
rehabilitation interventions for attention deﬁcits in 80.59% of the total 67 studies (n: 54),
with 70.18% being males (n = 1120) and 29.82% being females (n = 476).

Age was reported in eighty-eight percent of the studies (n=59). The mean age of
individuals with TBI across all studies was 29.5 years (ages ranged from 18 to 63 years).
The mean socioeconomic level was reported in only 16.42% of the studies (n=11). In
34.33% of the studies (n=23), researchers described the cultural/racial mix of the
subjects. Among those studies 68.72% of the subjects were White (n=512), 26.85% were
African Americans (n=200), 2.42% were Latino (n=18), 0.94% were American Indians
(n=7), and 1.07% were reported as other (n=8). Table 18 shows the breakdown of the
racial/cultural mix of participants. Severity of injury was reported in 100% of the studies
(n=67), with 16.28% being reported as mild TBI (n=360), 26.19% being reported as
moderate TBI (n=579), and 57.53% being reported as severe TBI (n=1272). Table 19

shows the breakdown of the severity of TBI.

131

Table 17: Cognitive Rehabilitation of Attention Deficits in Individuals with TBI:
Demographic Data on Subjects

 

Subject Category # Individuals % of Population
Sample # 2211 100

TBI Subjects # 1897 85.79%
Control Subjects # 314 14.21

 

Table 18: Cognitive Rehabilitation of Attention Deficits in Individuals with TBI:
Cultural/Racial Makeup of Subjects

 

Cultural Makeup of TBI Subjects # Individuals % of Population
White Americans 512 68.72%
African Americans 200 26.85%
Latino Americans 18 2.42%
American Indians 7 0.94%
Other 8 1.07 %

 

132

Table 19: Cognitive Rehabilitation of Attention Deficits Severity of TBI Subjects

 

 

Severity of TBI Subjects # Individuals % of Population
Mild TBI 228 12.02%
Moderate TBI 636 33.53%
Severe TBI 1033 54.45%

 

133

Cognitive Rehabilitation of Individuals with Attention Deficits following a TBI:

Acceptance or Rejection of the Hypothesis

The statistical results accepting or rejecting the original hypothesis, i.e., that

cognitive rehabilitation intervention will be positively correlated with the remediation of

attention deﬁcits following traumatic brain injury was tested. A t-test was computed on

the grand total of all ES scores. Overall, the total score data set has a mean ES score of

0.253 (n=831) and a Sd of 1.133. The t-test statistic was: tdf830=4.968, [p<.01], which

indicates that the overall results of cognitive rehabilitation intervention on individuals

with attention deﬁcits following a TBI is statistically signiﬁcant with alpha at the .01

level. Table 20 shows the statistics reported for the cognitive rehabilitation intervention

of attention deﬁcits. As can be seen, cognitive remediation as an intervention strategy is

effective in the treatment of attention deﬁcits following a TBI.

Table 20:

Statistical Results on the Cognitive Remediation of Attention Deficits
following TBI

 

Average ES: 0.253
Number: 831
Minimum Score: 10.763
Maximum Score: -4.198
Sd: 1.133
t-tests: 4.968
Outcome: *

 

* p<.01 is significant

A total of 831 effect size scores (ES) were calculated from the 67 studies. Means

and standard deviations were used to convert and compute 509 t-score category effect

size statistics (61.3%), while data from F tests accounted for 270 f-score category effect

size statistical conversions (32.45%), correlation scores accounted for 42 r-score

134

statistical conversions (5.05%), and 10 effect size scores were given without conversions
needing to be calculated. Table 21 shows the categories reported by researchers on the
variable effect size scores for cognitive rehabilitation of attention deﬁcits.

Table 22 shows the types of statistics reported by researchers in each study and
the average effect sizes on types of scores categories.

As before, the top 1% of the scores was removed in order to be consistent with the
investigation. To refresh the reader’s memory, the primary reason for removal of these
scores was that the top 8 scores were so different that the central tendency of scores is
distorted by their inﬂuence on ﬁnal calculations.

Because the investigator did not want to potentially skew the final results by
creating this new set of data, the results will be based on both the original total scores set
and the newly formed adjusted scores set and compare the patterns of the ﬁndings. The
same procedure that was used in the previous section was used for calculating the new
adjusted scores set. The process of selecting the outlier scores, their subsequent removal
and the creation of the adjusted scores are as follows: (I) calculate 1% of the total scores
which equals 8, (2) make a list and convert all scores to absolute scores, (3) select the
most extreme score, which equals 8, and (4) remove the 1% extreme scores from the total
score set, which becomes the adjusted score set which to compare the patterns of
statistical results too that of the total score set. Table 23 displays the eight most extreme
ES scores, their absolute values and category of scores.

After the most extreme 1% of the effect size scores have been removed, the
adjusted Effect Size scores were examined. There were three types of scores categories

affected by removing the extreme scores: the f-score category mean ES score decreased

135

to 0.421, while the t-statistic changed slightly from tdf269=13.364, [p<.01], to a t-value
for the adjusted data of tdf268=15.345, [p<.01], which is signiﬁcant. The resulting data
on the newly formed adjusted score set indicated an overall mean Es score of 0.141, a
standard deviation of 0.937 and a t-statistic of tdf822=4.023, [p<.01], a signiﬁcant level
of results. The ﬁnal comparison of the total score group with the adjusted score group on
t-statistics indicates the t-test value of tdf830=4.968, [p<.01], compared to the new value
of tdf822=4.329, [p<.01]. It appears that the reduction of these extreme scores will not
affect the overall results. Table 24 shows the types of statistics reported by researchers
and the average effect sizes on the type of scores categories from the cognitive
rehabilitation of attention deﬁcits adjusted score set.

Table 25 shows comparisons of the type of cognitive rehabilitation of attention
deficits statistics reported and the average sizes of the two score sets.

A comparative examination of the frequency distributions between each set of
scores indicates a change only in one positive extreme interval, i.e., removing the 8 most
extreme scores when ﬁgured as absolute values removes all 8 scores from the “greater
than one” interval on the positive end of the distribution. This results in a very modest
reduction in percent of the totals (0.77%) in the positive “greater than one” interval.

Table 26 shows the severity of injury data, the average effect sizes, and the
signiﬁcant category on the total score set. Following is table 27, which shows the
severity of injury data, the average effect sizes, and the significant category on the

adjusted score set.

136

Table 21: Effect Size Scores by Category, Number, and Percent of the Total

 

 

 

Category Number of Scores % of the Total

t-score 509 61.25%
f-score 270 32.49%
r-score 42 5.05%

Effect Size 10 1.20%
Total Scores 831

 

Note: average number of scores per remediation of memory study (based on 67 studies) 11.54

Range of effect sizes: 10.763 to -4.l98
Mean average of effect sizes across all attention studies: 0.253

Standard deviation: 1.133

 

 

Table 22: Cognitive Remediation of Attention Deficits on Individuals with TBI
Type of Score Categories

Category Frequency Mean ES SD t-test Signiﬁcance

f-score 270 0.440 0.540 13.364 *

r-score 42 1.182 1.888 4.009 *

Effect Size 10 0.637 0.622 3.074

t-score 509 --0.012 1.220 0222

Grand Total 831 0.253 1.133 4.968 *

 

*p<.01 is significant

 

137

Table 23:

The Eight most Extreme ES Scores for Cognitive Rehabilitation of
Attention Deficits following TBI

 

 

 

 

 

Mean Sd from Mean Type

ES Score of Score

10.763 9.21 1 t-score

7.213 6.080 t-score

6.857 5.724 r-score

6.083 4.950 t-score

5.667 4.534 t-score

5 .484 4.351 t—score

5.345 4.212 f-score

5.222 4.089 t-score

Table 24: Cognitive Remediation of Attention Deficits following TBI with Eight
Outlying Scores Removed

Category Frequency Mean ES Sd t-test Signiﬁcant

f-score 269 0.421 0.450 15.345 *

r-score 41 1.044 1.682 3.925 *

Effect Size 10 0.637 0.622 3.074

t-score 503 -0.092 0.964 -2.131

Grand Total 823 0.139 0.937 4.291 *

 

*p<.01 is signiﬁcant

138

Table 25: Comparison of Total Scores and Adjusted Scores for Cognitive
Rehabilitation of Attention Deﬁcits following TBI

 

Total Scores Adjusted Scores (extreme 1% scores)

Average ES: 0.253 0.139
Number: 831 823

Minimum: -4.198 -4.198

Maximum: 10.763 4.560
Standard

Deviation: 1.133 0.937
t-tests: 4.968 4.291
Outcome: significant results* significant results*

 

*p<.01 is significant

Table 26: Severity of Injury on Total Score Set

 

 

Category Frequency Mean ES Sd t-test Signiﬁcant
Severe TBI 497 0.197 1.013 3.922 *
Moderate TBI 286 0.138 1.170 2.046

Mild TBI 48 0.169 0.384 2.483

 

*p<.01 is signiﬁcant

139

Table 27: Severity of Injury on Adjusted Score Set

 

 

Category Frequency Mean ES Sd t-test Signiﬁcant
Severe TBI 491 0.143 0.860 3.342 *
Moderate TBI 284 0.098 1.065 1.595

Mild TBI 48 0.169 0.384 2.483

 

*p<.01 is significant

140

Introduction to Cognitive Rehabilitation of Socio—behavioral
Deficits in Individuals with TBI

Remediation of socio-behavioral deﬁcits has to do for the most part with what is
termed executive functioning. This refers to those integrative cognitive processes that
determine goal-directed and purposeful behavior and are essential for the execution of
daily living skills. The term socio-behavioral deficit encompasses a broad array of
cognitive functions and is most often associated with frontal lobe type injuries.
Individuals with these types of injuries tend to have deficits in the following areas: unable
to initiate behavior, anticipate consequences of their actions, to plan and organize
behavior, and to monitor and adapt behavior to ﬁt a particular task or event. In addition,
the most noticed of these disturbances tend to be related to impairment in emotional and
behavioral self-regulation and reduced capacity for insight. It should be noted that
deﬁcits in these areas are often difﬁcult to operationalize because they deal not only with
discrete skills but with the cognitive structures and processes that control the use of these
skills. The goal of these interventions is designed to establish external structure and or
internationalization of control of these actions.

The purpose of this section of the investigation was to collect and evaluate the
empirically based studies pertaining to cognitive remediation of socio-behavioral deﬁcits
following TBI (n=30).

The results of this section will be presented as it was for the other two sections,
i.e., descriptive results of cognitive rehabilitation of socio-behavioral deﬁcits following
TBI which are shown in tables 28 through 32, followed by statistical results which are

displayed in tables 33 through 40.

141

Cognitive Rehabilitation of Socio-behavioral Deficits Following TBI:
Study Characteristics
Thirty studies were examined in this area, with all 30 published in journals spanning the
years 1980 through 2003. The 30 studies had been published in journals of psychology,
brain injury, and cognitive rehabilitation journals.

Table 28 shows the sources of publication and provides a frequency distribution
of the studies published in this area. The top four major sources (n: 24) provided
80.00% of the total studies on cognitive rehabilitation of socio-behavioral deficits of this
investigation. They were Brain Injury (n = 10, 33.33%), Journal of Head Trauma
Rehabilitation (n = 8, 26.67%), Cognitive Rehabilitation (n = 4, 13.34%), and the Journal
of Consulting and Clinical Psychology (n = 2, 6.67%). The remaining 20.00% of the
studies (n = 6) were distributed across the 6 other sources.

Of the 30 studies, 12 (40.00%) were published during the period from 1980 to
1990, while the other 18 studies (60.00%) were published between 1991 and 2003. Table
29 and 30 shows the cognitive rehabilitation of socio-behavioral deﬁcits in individuals

with TBI studies by year.

142

Table 28: Cognitive Rehabilitation of Socio-behavioral Deficits in Individuals with

TBI: Sources of Publication

 

 

 

 

 

 

 

Journal Title Frequency % of Totals
American Journal of Art Therapy 1 3.33%
Brain Injury 10 33.33%
Cognitive Rehabilitation 4 13.34%
International Journal of Rehabilitation Research 1 3.33%
Journal of Head Trauma Rehabilitation 8 26.67%
Joumal of International Neuropsychology and Sociology l 3.33%
Journal of Communication Disorders 1 3.33%
Journal of Consulting and Clinical Psychology 2 6.67%
Neuropsychology 1 3.33%
Neurorehabilitation 1 3.33%
Totals 30 100.00%
Table 29: Cognitive Rehabilitation of Socio-behavioral Deficits in Individuals with
TBI: Studies Per Year from 1980 to 1990
# Studies Year % of Total Studies
Per Year

1 1980 3.3%

1 1981 3.3%

1 1982 3.3%

1 1983 3.3%

l 1984 3.3%

l 1985 3.3%

1 1986 3.3%

2 1987 6.6%

1 1988 3.3%

1 1989 3.3%

1 1990 3.3%

12 40.00%

 

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Table 30: Cognitive Rehabilitation of Socio-behavioral Deﬁcits in Individuals with
TBI: Studies Per Year from 1991 to 2003

 

 

 

# Studies Year % of Total Studies
Per Year
2 1991 6.66%
1 1992 3.33%
2 1993 6.66%
1 1994 3.33%
3 1995 10.00%
1 1996 3.33%
1 1997 3.33%
1 1998 3.33%
l 1999 3.33%
1 2000 3.33%
2 2001 6.66%
0 2002 0.00%
0 2003 0.00%
16 60.00%

 

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Cognitive Rehabilitation of Socio-behavioral Deficits in Individuals with TBI:
Subjects Characteristics

The 30 studies comprise a sample population of 810 individuals with TBI
receiving cognitive rehabilitation intervention for socio-behavioral deﬁcits. The number
of individuals per study ranged from 9 to 56, with an average 27 individuals per study.
Table 31 displays the subjects’ demographic data in studies of cognitive rehabilitation of
socio-behavioral deficits.

Research studies reported the gender of individuals with TBI receiving cognitive
rehabilitation interventions for socio-behavioral deﬁcits in 86.66% of the total 30 studies
(11: 26), with 76.97% being males (n = 498) and 23.53% being females (n = 149).

Age was reported in all 30 studies (n=30). The mean age of individuals with TBI
receiving treatment for socio—behavioral deficits across all studies was 31.3 years (ages
ranged from 18 to 59 years). The mean socioeconomic level was reported in only 30% of
the studies (n=9). Researchers described the cultural/racial makeup of the participants in
only 20.00% of the studies (n=6). Severity of injury was reported in only 43.33% of the
studies (n=13), however, based upon the data such as length of time in coma, the
researcher was able to determine severity of injury in 83.33 % of the studies (n = 25).
The studies reported that 9.36% of the individuals had a mild T BI (n=56), 32.94% being
reported as moderate TBI (n=197), and 57.69% being reported as severe TBI (n=345).

Table 32 shows the breakdown of the severity of TBI.

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Table 31: Cognitive Rehabilitation of Socio-behavioral Deﬁcits of Individuals with
TBI: Demographic Data on Participants

 

 

Subject Category # Individuals % of Population
Sample # 810 100%
Experimental Subjects # 547 67.50%
Control Subjects # 263 32.47%

 

Table 32: Cognitive Rehabilitation of Socio-behavioral Deficits of Individuals with
TBI: Severity of TBI Participants

 

 

Severity of TBI Subjects # Individuals % of Population
Mild TBI 56 10.24%
Moderate TBI 177 32.35%
Severe TBI 314 57.41%
Total 547 100.00%

 

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Cognitive Rehabilitation of Individuals with Socio-behavioral Deficits following a TBI:

Acceptance or Rejection of the Hypothesis

The statistical results accepting or rejecting the original hypothesis, i.e., that there

will be no difference in the use of cognitive rehabilitation intervention in the remediation

of socio-behavioral deﬁcits following traumatic brain injury was examined in this

section. A t-test was computed on the grand total of all BS scores. Overall, the total score

data set has a mean ES score of 0.260 (n=481) and a Std. Deviation of 1.013. The t-test

statistic was: tdf480=4.232, [p<.01], which indicates that the overall results of cognitive

rehabilitation intervention on individuals with socio-behavioral deﬁcits following a TBI

is statistically signiﬁcant with alpha at the .01 level. Table 33 shows the statistics

reported for the cognitive rehabilitation intervention of socio-behavioral deficits.

Table 33:

Statistical Results on the Cognitive Remediation of Socio-behavioral
Deficits following TBI

 

Average ES: 0.163
Number: 481
Minimum Score: 8.655
Maximum Score: —5.164
Std. Deviation: 1.013
t-tests: 3.464
Outcome: *

 

* p<.01 is significant

A total of 481 effect size scores (ES) were calculated from the 30 studies. Means

and standard deviations were used to convert and compute 305 t-score category effect

size statistics (63.41%), while data from F tests accounted for 130 f-score category effect

size statistical conversions (27.03%), correlation scores accounted for 31 r-score

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statistical conversions (6.44%), and 15 effect size scores (3.12%) were given without
conversions needing to be calculated. Table 34 shows the cognitive rehabilitation of
socio-behavioral deﬁcits categories reported by researchers on the variable effect size
scores.

Table 35 shows the types of statistics reported and the average effect sizes on
cognitive rehabilitation of socio-behavioral types of scores categories.

To be consistent with the investigation, the top 1% of the scores was removed.
These top 5 scores were greater than three standard deviations from the mean, and in
sampling distributions it is considered extremely rare for score(s) to fall that far from the
mean.

As before, the final results from this new set of data will be based on both the
original total scores set and the newly formed adjusted scores set. The patterns of the
ﬁndings will be compared. As shown previously the most extreme scores were removed
using the same procedures as in the previous two sections and the new scores calculated.
Table 36 shows the five most extreme ES scores values and category of scores.

After the most extreme 1% of the effect size scores were removed, the adjusted
Effect Size scores were examined and only the t-score category score changed slightly.
The data on all the other categories remained the same. As a result, the mean Effect Size
of the t-score category decreased from 0.026 to 0.014, while the number of scores
decreased from 481 to 476 (5 less), and the standard deviation decreased from 1.143 to
1.013. The t—statistic changed slightly from tdf305=—0.165, [p<.01], to a t-value for the
adjusted data of tdf300 = 0.216, [p<.01], which is signiﬁcant. The resulting data on the

newly formed adjusted score set indicated an overall mean ES score of 0.137, a standard

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deviation of 0.869 and a t-statistic of tdf476 = 3.964, [p<.01], a signiﬁcant level of
results. The final comparison of the total score group with the adjusted score group on t-
statistics indicates the t-test value of tdf481=3.464, [p<.01], compared to the new value of
tdf822=3.964, [p<.01]. It appears that the reduction of these extreme scores will not
affect the overall results. Table 37 shows cognitive remediation of socio-behavioral
deﬁcits following the removal of the ﬁve outliers.

Table 38 shows comparisons of the type of cognitive rehabilitation of socio-
behavioral deficits statistics reported and the average sizes of the two score set.

Table 39 shows the data for severity of injury reported by researchers, the average
effect sizes, and the one signiﬁcant category for the total score set and table 40 shows the

severity of injury data reported, and the average effect sizes on the adjusted score set.

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Table 34: Effect Size Scores by Category, Number, and Percent of the Total

 

 

 

Category Number of Scores % of the Total

t-score 305 63.41%
f-score 130 27.03%
r-score 3 1 6.44%

Effect Size 15 3.12%
Total Scores 481

 

Note: average number of scores per remediation of memory study (based on 67 studies) 11.54
Range of effect sizes: 8.655 to -5.164
Mean average of effect sizes across all attention studies: 0.163

Standard deviation: 1.013

 

 

Table 35: Cognitive Rehabilitation of Socio-behavioral Deficits in Individuals with
TBI: Type of Score Categories

Category Frequency Mean ES SD t-test Significance
f-score 130 0.312 0.467 6.397 *
r-score 31 1.113 1.687 3.069 *
Effect Size 15 0.913 0.877 4.802 *
t-score 305 0.026 1.143 -0.165

Grand Total 481 0.163 1.013 3.464 *

 

*p<.01 is significant

 

150

 

 

 

 

 

Table 36: The Five most Extreme ES Scores for Cognitive Rehabilitation of Socio-
behavioral Deﬁcits following TBI

Mean Sd from Mean Type

ES Score of Score

8.655 7.642 t-score

8.379 7.366 t-score

7.864 6.851 t-score

7.223 6.210 t-score

7.026 6.013 t-score

Table 37: Cognitive Rehabilitation of Socio-behavioral Deficits following TBI with
Five Outlying Scores Removed

Category Frequency Mean ES SD t—test Signiﬁcant

f-score 130 0.312 0.467 6.397 *

r-score 31 1.113 1.687 3.069 *

Effect Size 15 0.913 0.877 4.802

t-score 300 0.014 1.013 -0.216

Grand Total 476 0.137 0.869 3.964 *

 

*p<.01 is signiﬁcant

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Table 38: Comparison of Total Scores and Adjusted Scores for Cognitive
Rehabilitation of Socio-behavioral Deﬁcits following TBI

 

Total Scores Adjusted Scores (extreme 1% scores)

Average ES: 0.163 0.137
Number: 481 476

Minimum: 8.655 4.164

Maximum: -5.164 -5.164
Std. Deviation: 1.013 0.869
t-tests: 3.464 2.873
Outcome: significant results* signiﬁcant results*

 

*p<.01 is significant

Table 39: Severity of Injury on Total Score

 

 

Category Frequency Mean ES Sd t-test Signiﬁcant
Severe TBI 300 0.463 1.598 2.717 *
Moderate TBI 139 0.495 0.136 5.160

Mild TBI 42 0.195 0.482 2.286

 

*p<.01 is significant

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Table 40: Severity of Injury on Total Score

 

 

Category Frequency Mean ES Sd t-test Significant
Severe TBI 295 0.373 1.013 3.021 *
Moderate TBI 139 0.495 0.136 5.160

Mild TBI 42 0.195 0.482 2.286

 

*p<.01 is signiﬁcant

153

CHAPTER V
CONCLUSIONS
Introduction to Discussion and Conclusion Section

The purpose of this research is to determine the effectiveness of cognitive
rehabilitation interventions in enhancing memory, attention, and socio-behavioral deﬁcits
of individuals with TBI. The aim is to assimilate and synthesize the literature regarding
the impact of cognitive rehabilitation interventions.

Meta-analysis as an area of statistical investigation has gained credibility over the
years. However, within the field of counseling, there are still mixed reviews for meta-
analysis as a statistical procedure. Wolf (1986) argues that there are four criticisms of
meta-analysis. First, he argues that logical conclusions cannot be made by comparing and
aggregating studies that include different measuring techniques, definitions of variables,
and subjects because of their differences. Second, according to Wolf, results of a meta
analysis are not interpretable because results from “poorly” designed studies are included
along with results from “good” studies. Thirdly, published research is biased in favor of
signiﬁcant ﬁndings because ﬁndings that are not signiﬁcant are rarely published, and
fourth, multiple results from the same study are often used which may bias or invalidate
the meta analysis and make the results appear more reliable than they really are, because
the results are not independent.

The present investigation has taken precautions to minimize the impact of these
limitations. In terms of criticism one, this investigation developed a set of criteria in order
to include studies into the data set. This research design and methodology dealt with the

dissimilarity through data coding, classification and categorization. As a result of those

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criteria and good research design in the present investigation, I believe criticism one was
met.

Criticism two focuses on including good studies with badly designed studies.
Again, I believe that this was addressed within this study as a result of the classiﬁcation
method employed within this investigation. The investigative method for the data coding
incorporated categories that eliminated studies that did not meet the criteria specified.
Criticism three addresses the issue that there may be a tendency for ES scores to be
higher for those published studies versus studies that has not been published. There may
indeed be a tendency for ES scores to be higher in research studies that are published
versus those that are not. This investigation took approximately four years to read and
review studies used in this research. As there isn’t a list of unpublished research, the
statistical ES scores from the results of this investigation may indeed be higher than if
more of the un-published studies were included. As such, this investigation can not be
compared against a body of literature that could not be accessed.

Criticism four which addresses multiple results as being biased, tends to be
somewhat philosophic. It can be argued that all investigative research tends to be biased
in the collection of data, i.e., the selection format, the investigative design, and the
research methods used. The summation of data for this research is based on what was
reported in the various studies. Multiple results in this investigation tend to corroborate
each others ﬁndings. This investigation includes the comparisons of certain ﬁndings with
those of other similar research investigations so the patterns of similarities and
differences can be examined. As is with all empirical research, it should be considered

merely as a comparison study or as a review that has its own strengths and limitations. As

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Harber (1981, p.260) stated, the “average reader should not accept uncritically as true
everything reported in this or any other published literature.”
Conclusions and Recommendations
This section will interpret the ﬁndings of the meta-analytic review in a narrative
form as well as discuss methodological issues involved in cognitive rehabilitation and
present recommendations for future research in cognitive rehabilitation interventions with
individuals with TBBI. Conclusions are reached and recommendations are formulated.
The conclusions based on the findings are presented for each research question
separately. The research question is stated and followed by conclusions based on the
ﬁndings related to it.
Research Question Number One:
How effective is cognitive rehabilitation intervention on the remediation of memory
deﬁcits following traumatic brain injury?
Statistical Conclusions on the Cognitive Rehabilitation of
Memory Deﬁcits in Individuals with TBI
In terms of the effectiveness of cognitive rehabilitations on memory deficits
following a TBI, it appears that the intervention is effective. The statistical results on the
type of scores variables shows that f-score, ES-score, r-score, and the t-score all indicate
statistical levels as p<.01. The t-test generated on the total score data determines the
original hypothesis that u = 0, is rejected. The mean ES score of 0.390 was transformed
into a final t-test statistic of tdf1783=8.403, [p<.01] which means that the use of cognitive
remediation is effective as an intervention strategy in improving memory in individuals

with TBI. This was also true for the adjusted score set with the 1% most extreme scores

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or outliers being removed for statistical analysis. The adjusted mean ES score was 0.303,
which was transformed to a ﬁnal t-test statistic of tdf1767=9.752, [p<.01]. The increase
for the adjusted score set being signiﬁcant was attributed to reducing the variability of the
sample, by the removal of those 1% scores that fell more than three standard deviations
from the mean.

Despite the fact that the investigation showed that cognitive rehabilitation of
memory deﬁcits is effective for individuals with TBI, there are reasons why one needs to
be careful regarding a signiﬁcant result in this case. As a result of many signiﬁcant
variables not being reported in the study, the investigator was unable to analyze their
impact on the outcomes of the interventions. For example, many signiﬁcant variables
such as age, ethnic origin, gender, SES, and level of education were not reported in many
studies and as a result no statistics could be done on these variables. In addition, in
regards to severity of injury, many of the studies that were included in this investigation
used participants that had moderate to severe injuries. As a result, the statistical accuracy
of this investigation may be questioned in regards to the severity of injury category. As
such, the research literature could be regarded as mediocre in the overall positive effects
of cognitive rehabilitation intervention with individuals with TBI who have experienced
memory deﬁcits.

The statistical results shows that the f-score, the ES-score, r-score, and the t-score
all indicate statistic that were signiﬁcant at the p<.01 level. A similar pattern was noted
on the adjusted score set.

The severity of injury was reported in approximately 80% of the research used to

evaluate cognitive rehabilitation on memory deficits. In the variable severity of injury,

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higher mean effect size scores were associated with severe injury and moderate type
injury, which suggest that the more severe the injury the more effective is cognitive
rehabilitation on the remediation of memory deficits following a TBI. This same pattern
was noticed in the results for the adjusted score set. Based upon the literature, individuals
with mild TBI tend to have more success or positive outcomes following intervention
with cognitive rehabilitation. However, in this study, significance was obtained with
individuals with severe TBI. This result could be attributed to non-reporting of severity of
injury by researchers. In addition, most of the studies reviewed consist of participants that
had severe TBI which would account for severe TBI being statistically signiﬁcant. What
can be learned from this research is that individuals with severe TBI benefited from
cognitive rehabilitation intervention; however, one cannot conclude that this means that
individuals with mild and moderate TBI do not beneﬁt from this intervention as
compared to individuals with more severe injuries.

In addition, many studies used cognitive rehabilitation interventions to target
speciﬁc skills and domain-specific knowledge rather than focusing on improving overall
memory functions, which appear to be more effective with individuals with moderate to
severe impairment. No signiﬁcant interpretation can be concluded from this ﬁnding as a
result of non-reporting of variables or whether or not the results are due to spontaneous
recovery. Thus, insufficient evidence exists to distinguish the effects of cognitive
rehabilitation on specific memory training from those that may result spontaneous
memory recovery. As such, one cannot conclude from this study that individuals with
mild TBI do not benefit from cognitive rehabilitation interventions as the literature

suggest. However, one may infer that individuals with mild TBI may not require

158

cognitive rehabilitation intervention as readily as individuals with moderate and severe
TBI as a result of higher cognitive functioning and the lack of severe impairment or
deﬁcit that may affect individuals with more severe type injuries.

In summary, the information gained from this Meta analysis is that it is possible
to intervene with memory impairment. However, it should be noted that there are
multiple shortcomings in the information being reported in the literature, which may limit
the conﬁdence that can be placed on the results. For example, not many of the studies
used in this meta-analytical review have been replicated. Also as noted previously, many
of the studies did not report on variables deemed important by many experts in the ﬁeld.
In addition, many studies lack a design adequate to the challenge of unambiguous
interpretation as well as many of the earlier studies did not based their research on current
knowledge regarding brain function in memory processes.

As a result, the treatment of memory impairment constitutes a signiﬁcant
challenge to rehabilitation professionals. There does not appear to be strict evidence of a
standardized treatment protocol that has universal effectiveness. There are many
theoretical opinions and some research based reports that some treatments may be more
effective under some situations. A likely possibility of furthering the development of
treatment methods is to examine what memory skills may be present in individuals with
TBI. Parkin (1982) reports that even in severe cases of memory loss following TBI, there
may be sparing of more than one type of memory. As a result of knowing what type of
memory remains in individuals with TBI may provide direction to the development of

treatment protocols.

159

As previously stated, different types of treatment may be effective in different
individuals with TBI depending upon the type of injury, the type of memory deficit
(episodic, verbal, visual), and the type of information to be remembered (daily schedules,
names of people). As a result, treating individuals with TBI may require a combination of
treatment interventions, which may make it difficult for researchers to have consistency
in treatment protocol.

Descriptive Conclusions on the Cognitive Rehabilitation of
Memory Deficits Study Characteristics
The investigation addressed studies published from 1980 through 2003. An
important feature of this was that of the 120 studies reviewed for this area, the majority of
studies, approximately 76% were published in ﬁve major journals (n=93) during this
period. This is important as it appears that these journals are committed to cognitive
rehabilitation interventions in the treatment of memory impairments. One would have to
assume that the reviewers and editorial board would require though standards. In
addition, there were almost equal distribution of the studies published from 1980 through
1990 (n=56) and studies published from 1991 through 2003 (n=64). It should be noted
that majority of studies that were reviewed were from the period spanning 1980 through
1990. However, most of those studies were not used because they did not met the
inclusion criteria. In fact, it appears that the studies published from 1991 through 2003
had a more rigorous statistical content as well as reported more of the associated
variables such as age, severity of injury, etc. As such, it appears that in order to obtain
more statistical power, it would be more advantageous to examined studies from the

19908 to present. Additionally, if we looked at studies from 1990 to 2003 for this

160

investigation, the majority of studies would have been within this time period, i.e.,
approximately 60% of the studies. These studies were able to satisfy more of the criteria
required for this investigation as many of the studies were appropriate in their design and
the research was based on current knowledge regarding brain function in memory
processes.
Descriptive Conclusions on the Cognitive Rehabilitation of
Memory Deficits Participant Characteristics

In terms of the subject characteristics, researchers did an adequate job in reporting
the gender within the studies, approximately 76.66% of the total of 120 studies. It is also
interesting to note the more than 3 to 1 margin of male to female ratio. From a study
perspective, this may look inappropriate, however, this is in line with the ratio between
males and females in terms of who acquires a traumatic brain injury.

With respect to age of the participants, the sample ranged from 18 to 56 years,
with an approximate mean age of 33.4 for participants involved in the remediation of
memory deﬁcits. It should be noted that a majority of the studies reported the age of the
participants in ranges; as such the mean age calculation may not be as accurate as a result
of how the data was presented.

In the cultural/racial category, researchers reported the makeup of the participants
in only 26.66% of the total of the 120 studies used in this section. It should be noted that
Whites/European Americans constitute the largest cultural/racial group receiving
cognitive remediation intervention.

On the variable of severity of injury, researchers reported the severity in

approximately 87.5% of the studies (n=105). Of this, the majority 65.11% of the

161

participants were classified as having a severe injury. This is important in understanding
what level of severity is most likely to beneﬁt from cognitive rehabilitation interventions
and subsequently what level of severity is most likely to eventually gain employment. It
appears that individuals with severe T B1 are more likely to receive cognitive
rehabilitation intervention treatment as a result of the deficits associated with more severe
type injuries and the debilitating effects these deﬁcits may have on the individual quality
of life. Many individuals with mild TBI do not seek treatment. As stated previously in
the literature review, many individuals with mild TBI do not even seek emergency
treatment.

On the socio-economic variable, researchers reported the SES of participants in so
few studies, approximately 9% that for this investigation it was impossible to address this
variable. Based upon this, one can conclude that the researchers do not believe that SES
is an important or significant category in the study of cognitive rehabilitation of memory
deﬁcits following TBI. However, this researcher believes that by not addressing SES,
one is unsure which groups are likely to obtain these types of remediation interventions
and subsequently have a positive vocational outcome.

Research Question Number Two:
How effective is cognitive rehabilitation intervention on the remediation of attention
deﬁcits following traumatic brain injury?
Statistical Conclusions on the Cognitive Rehabilitation of
Attention Deﬁcits in Individuals with TBI
As before, the t-test was computed on the grand total of all BS score. This t-test

statistic on the total data set was tdf830=5.161, [p<.01], which indicates that cognitive

162

rehabilitation of attention deficits in individuals with TBI is statistically significant, i.e., it
has a positive effect on enhancing or improving those areas of attention that the
intervention was based on. The results were also positive for the adjusted score set, which
as stated before included the removal of the extreme 1% scores that were more than three
standard deviations from the mean. A statistical analysis was done on the remaining
scores and the new data indicated statistical significance with a t-statistic of
tdf822=4.291, [p<.01].

Statistical results indicate higher effect size scores were associated with the f-
score followed by the r-score category. This was also true for the f-score with the
adjusted score set. Once again, there was an increase for the adjusted f-score category.
This significant increase is also attributed to reducing the variability of the sample, by the
removal of those 1% scores that fell more than three standard deviations from the mean.
It appears that the f-scores that were provided were in studies that had individuals with
more severe TBI. The higher effect size was associated with severe injuries. The pattern
associated with these results would indicate cognitive interventions do not improve the
performance of individuals with mild TBI, however, it does improve the performance of
individuals with moderate to severe TBI.

This investigation does indicate that cognitive rehabilitation of attention deﬁcits is
effective for individuals with TBI. However, a word of caution must be addressed. Of
the 67 articles reviewed, a good number of studies did not report on many variables
deemed important in understanding the effectiveness of treatment on the outcome. As
mentioned before, many signiﬁcant variables such as age, ethnic origin, gender, SES, and

level of education were not reported in many studies and as a result no statistical analysis

163

 

could be done on these variables. In addition, many researchers did not report the exact
numerical value of an effect size but stated that the results were signiﬁcant. In such cases
the effect size were calculated based upon the values provided. As such, statistical
analysis may not be as accurate as it should be as many studies lacked a design that was
adequate for appropriate interpretation. In my view, the research literature could be
regarded as being of poor quality in the overall positive effects of cognitive rehabilitation
intervention with individuals with TBI who have attention deﬁcits. For example, many
of the intervention used to address remediation of attention impairments have generally
relied on drill and practice, with exercises designed to address speciﬁc aspects of
attention (e. g., processing speed, focused attention, divided attention). Additionally,
many of the reported interventions have used stimulus-response paradigms, which
required participants to identify and select among relevant auditory or visual stimuli, and
often used speeded stimulus presentations. However, many of these studies failed to
explicitly state the rationale for using such interventions. It could be assumed that the
implicit rationale is to restore basic attention abilities through repeated practice, however,
the studies failed to address such issues.

The statistical results shows that the f—score and r-score indicate statistic that were
significant at the p<.01 level. A similar pattern was noted on the adjusted score set.

The severity of injury was reported in approximately 58% of the research used to
evaluate cognitive rehabilitation on attention deﬁcits following a TBI. In the variable
severity of injury, higher mean effect size scores were associated with severe and
moderate type injury. This indicates that in this review, individuals with moderate and

severe injury beneﬁted most from cognitive rehabilitation interventions on the

164

remediation of attention deficits following a TBI. This same pattern was noticed in the
results for the adjusted score set. Although the results were positive for cognitive
rehabilitation intervention it is difficult for one to generalize the beneﬁts attributed to
attention remediation. Many of the studies have concentrated on providing participants
with practice on training tasks related to specific aspects of attention. Many authors have
argued that with such intervention the quality of therapeutic intervention beyond the
training tasks employed may be an important variable in the effectiveness of treatment.

It appears from the research that interventions aimed at remediating attention
appears to be more effective when aimed at improving functional tasks rather than
speciﬁc tasks. What can be learned from this research is that individuals with moderate to
severe attention deﬁcits appear to beneﬁt from cognitive rehabilitation interventions.
However, the evidence is insufﬁcient to distinguish the improvement to cognitive
rehabilitation intervention or to spontaneous recovery. In approximately 74% of the
studies reviewed, the participants were receiving inpatient brain injury rehabilitation that
included interventions aimed at orientation, memory, language, and other general
cognitive skills. In addition, only three of the studies reviewed compared recovery of
attention between treated and untreated subjects. As such, it could be argued that any
improvements attributable to the natural course of recovery and those related to cognitive
rehabilitation interventions within the conﬁned of a brain injury rehabilitation program
may be confounded.

In summary, it can be concluded that cognitive rehabilitation intervention does
appear to have some type of positive effect on decreasing attention deficits following TBI

for individuals with moderate and severe injuries. Individuals with TBI may experience

165

deficits in speed of information processing, selective attention, divided attention, etc.
Consequently, cognitive remediation interventions have emphasized practice on tasks that
exercise skills in ignoring distraction and in maintaining attention over time. Many of the
studies used have demonstrated improved performance with repeated practice on
attention tasks. However, as previously stated for memory impairments, the use of
cognitive remediation in the treatment of attention deﬁcits also have many shortcomings
that may impede the confidence that can be placed on the results. Many of the studies did
not report on variables deemed important by many experts in the field, i.e., type of
attention deﬁcit being treated, years post injury, severity of injury, years of education,
etc. In addition, many studies lack an appropriate design as such many of the
interpretation may be suspect. Also, it appears that the vast majority of studies on
cognitive rehabilitation of attention deficits utilized computerized cognitive rehabilitation
as the primary intervention technique, whereas others utilize attention process training
(ATP), and workbooks. In addition, as previously stated the vast majority of the
intervention was performed in brain injury rehabilitation programs at the same time
participants were receiving treatment for other areas affected. All this may account for
the lack of signiﬁcance with this intervention for individuals diagnosed with a mild TBI.
In most cases, individuals with mild TBI do not seek emergency treatment and do not
experience the severity of deﬁcits as individuals with moderate and severe TBI
experience; therefore this may account for the limited numbers of individuals with mild
TBI in the results and subsequently the lack of signiﬁcance for this group in this study.
The evidence for rehabilitation effectiveness of attention training stands out

among all others, however, it is not at the stage where it can be recommended routinely

166

as there does not appear to be signiﬁcant evidence for its generalizability to daily life. In
addition, it is not clear from the research what kinds of intervention may be more
effective and for what type of deﬁcit. Also it should be noted that in the studies reviewed,
many of the subjects were receiving inpatient brain injury rehabilitation that included
interventions directed at orientation, memory, or general cognitive skills. As such, it may
be necessary to examine and compare improvement in attention between subjects
receiving treatment in an inpatient setting and those not receiving treatment. Therefore, it
is difﬁcult to interpret whether improvements may be attributable to the natural course of
recovery or to cognitive interventions.
Descriptive Conclusions on the Cognitive Rehabilitation of
Attention Deficits Study Characteristics

The investigation addressed studies published from 1980 through 2003. This
investigation utilized 67 studies for this area. The overwhelming majority of studies,
approximately 85% were published in five major journals (n=57) during this period.
These were the Journal of Head Trauma Rehabilitation, Cognitive Rehabilitation, Brain
Injury, Neuropsychological Rehabilitation, and Journal of Clinical Neuropsychology. In
addition, approximately 43% of the studies were published from 1980 through 1990
(n=29) and 57% of the studies were published from 1991 through 2003 (n=38). It should
be noted that the majority of studies that were reviewed were from the period spanning
1980 through 1990, however many were not used because they did not met the inclusion
criteria. The studies published from 1991 through 2003 seem to met a more rigorous
statistical criteria and did report more of the associated variables such as age, severity of

injury, etc.

167

Descriptive Conclusions on the Cognitive Rehabilitation of
Attention Deficits Participant Characteristics

In terms of the subject characteristics, researchers did an adequate job in reporting
the gender within the studies, approximately 81% (n=54) of the total of 67 studies. It is
also interesting to note the more than 3 to 1 margin of male to female ratio.
Approximately 70% (n=1120) were males and 30% (n=476) females.

Age was reported in 88% of the studies, with the sample ranging from 18 to 63
years, and an approximate mean age of 29.5years for participants involved in the
remediation of attention deﬁcits studies.

In the cultural/racial category, researchers reported the makeup of the participants
in only 34.33% of the total of the 67 studies. This is signiﬁcant because most studies
completed on minority clients seem to indicate that these groups tend to have a higher
unemployment rate after disability, even after they have gone through training and
programs geared towards improving employment. Within this group category,
Whites/European Americans constitute the largest cultural/racial group receiving
cognitive remediation intervention, approximately 69%, followed by African Americans
at 27%.

On the variable of severity of injury, researchers reported the severity in all the
studies used for this investigation (100%). The majority of the participants, 58% were
classiﬁed as having a severe injury, followed by moderate type injury at 26%, and mild
TBI constituting the remaining 16%. This is important in understanding what level of
severity of injury is most likely to beneﬁt from cognitive rehabilitation interventions and

subsequently what level of severity is most likely to eventually gain employment.

168

The socio-economic variable was only reported in 16% of the studies utilized for
this investigation. It appears that researchers do not believe SES is an important or
significant variable in the study of cognitive rehabilitation interventions of attention
deﬁcits following TBI.

Research Question Number Three:
How effective is cognitive rehabilitation intervention on the remediation of socio-
behavioral deﬁcits following traumatic brain injury?
Statistical Conclusions on the Cognitive Rehabilitation of
Socio-behavioral Deficits in Individuals with TBI

The t—test was computed on the grand total of all BS scores. This t-test statistic on
the total data set was tdf480=4.232, [p<.01], which is statistically significant. This
indicates that cognitive rehabilitation of socio-behavioral deficits in individuals with TBI
has a positive effect on enhancing or improving those areas of socio-behavioral deﬁcits
that the intervention was based on. It should be noted that the f-score, r-score, and ES-
score were all signiﬁcant. The results were also positive for the adjusted score set, which
included the removal of the extreme 1% scores that were three standard deviations from
the mean. A statistical analysis was done on the remaining scores and the new data
indicated statistical significance with a t-statistic of tdf476=3.964, [p<.01]. As before,
statistical results indicate higher effect size scores were associated with the f-score
category. This was also true for the f-score with the adjusted score set.

This investigation does indicate that cognitive rehabilitation of socio-behavioral

deficits is effective for individuals with TBI. .

169

The statistical results shows that the f-score and r-score indicate statistic were
significant at the p<.01 level. A similar pattern was noted on the adjusted score set.

In the variable severity of injury, higher mean effect size scores were associated
with severe type injury. This indicates that the more severe the injury the more effective
is cognitive rehabilitation on the remediation of socio-behavioral deﬁcits following a
TBI. This same pattern was noticed in the results for the adjusted score set. What can be
learned from this research is that individuals with socio-behavioral deficits who have
been diagnosed with a severe TBI will benefit from cognitive rehabilitation interventions
as a result of the severity of the impairment. This is not to say that individuals with
moderate or mild injuries do not beneﬁt from cognitive rehabilitation. They may benefit
but not as much as individuals with more severe impairments.

It is important to understand that although emotional and psychosocial issues are
amongst the most significant variables inﬂuencing outcomes in individuals with TBI,
there has not been an abundance of research done in this area., i.e., only 30 studies were
used in this section. Behavior modification has been the most widely used intervention
for the treatment of socio-behavioral deﬁcits and the efﬁcacy of this intervention is well
established. On the other hand, the lack of research in this area may be due to the
complexity of the problems posed by socio-behavioral deﬁcits as well as the lack of
research tools to enable the researcher to investigate the ﬁeld appropriately. Many of the
instruments that exist are used with psychiatric patients and may be inappropriate or very
misleading when used with the TBI population.

As a result of the aforementioned problems as well as lack of reporting in many

studies the results must be approach cautiously. Additionally, many studies did not

170

indicate whether they were addressing emotional, social, or financial issues associated
with psychosocial factors. It appears that many of the studies that used cognitive
rehabilitation interventions to address socio-behavioral deﬁcits utilize verbal self-
instruction, self-questioning, and self-monitoring techniques in order to address those
issues, including the reduction of problem behaviors in everyday situations. However,
many of the studies did not incorporate or provide detailed neuropsychologic information
and or clinical assessment data necessary in identifying the type of relevant behaviors
that were being addressed. Some individuals, especially those with multiple cognitive
impairments, may require consistent external structure and environmental management to
achieve improvements in skills or behaviors within limited contexts. In addition, socio-
behavioral deﬁcits may include efforts to assess the participant’s awareness of their
deﬁcits and to improve the accuracy of their self-appraisal of their performance. Within
the thirty studies used to determine the effectiveness of cognitive rehabilitation
intervention, none of these concerns were adequately addressed through controlled
studies.
Descriptive Conclusions on the Cognitive Rehabilitation of
Socio-behavioral Deﬁcits Study Characteristics

The investigation addressed studies published from 1980 through 2003. This
investigation utilized 30 studies for this area. The overwhelming majority of studies,
approximately 77% were published in ﬁve major journals (n=23) during this period. In
addition, the majority of studies, approximately 60% were published from 1991 through

2003 (n=18) and the remaining 40% were published from 1980 through 1990 (n=12). It

171

should be noted that only few studies on cognitive rehabilitation have been published in
the area of socio-behavioral deficits.
Descriptive Conclusions on the Cognitive Rehabilitation of
Socio-behavioral Deficits Participant Characteristics

In terms of the subject characteristics, researchers reported the gender of
individuals within 87% (n=26) of the studies. Approximately 77% (n=498) were males
and 23% (n=149) were females.

Age was reported in all 100% of the studies, with the sample ranging from 18 to
59 years, with an approximate mean age of 31.3 years for participants involved in the
remediation of socio-behavioral deﬁcits.

In the cultural/racial category, researchers reported the makeup of the participants
in only 20% of the total of the studies.

On the variable of severity of injury, researchers reported the severity of injury in
only 43% (n=13) of the studies used for this investigation. The majority of the
participants, 58% were classiﬁed as having a severe injury, followed by moderate type
injury at 33%, and mild TBI constituting the remaining 9%. This is important in
understanding what level of severity of injury is most likely to beneﬁt from cognitive
rehabilitation interventions and subsequently what level of severity is most likely to
eventually gain employment.

The socio-economic variable was only reported in 30% of the studies utilized for
this investigation. As stated previously, SES does not appear to be an important or
signiﬁcant variable in the study of cognitive rehabilitation interventions of socio-

behavioral deficits following TBI.

172

Research Question Number Four:

What are the relationships between factors such as age at time of accident, years of
education, socio-economic status, severity of injury, and ethnic background of
individuals on subsequent vocational outcomes following cognitive rehabilitation
intervention with persons with T BI?

As previously stated, non-reporting was a signiﬁcant part of this investigation. In
all but one category, researchers did not provide adequate or enough information on
variables deemed important for cognitive rehabilitation with individuals with TBI. The
vast majority of studies did not provide data on the age of individuals at time of injury,
years of education, socio-economic status, and ethnic background. As such, too few
studies would have been used in completing a statistical analysis on these variables,
which in my view would have not been statistically signiﬁcant. In terms of severity of
injury, there seems to be clear evidence that individuals with severe type injuries appear
to benefit more from cognitive rehabilitation interventions. Researchers reported that
2,083 participants had a severe injury, which accounted for approximately 67% of the
total population reported for the treatment group. Moderate brain injury accounted for
28% of the treatment group, and mild brain injury represent 5% of all the participants that
were reported in this category. Within this investigation, cognitive remediation with
individuals with severe TBI reached signiﬁcance in all of the areas examined, i.e.,
cognitive rehabilitation of memory deﬁcits, attention deﬁcits and socio-behavioral
deficits. In terms of cognitive rehabilitation of memory deﬁcits in individuals with TBI,
a t-test statistic revealed moderate and severe injury were signiﬁcant at the p<.01 level.

The same pattern was found for the rehabilitation of attention deﬁcits, which showed

173

signiﬁcance for moderate and severe injuries at the p<.01 level, and for rehabilitation of
socio—behavioral deficits, which showed significance for severe injury at the p<.01 level.

It appears that cognitive rehabilitation has a signiﬁcant impact on the remediation
of memory, attention, and socio-behavioral deﬁcits for individuals with severe TBI based
upon the results of this study. In addition, statistical signiﬁcance was obtained for
individuals with moderate TBI in the rehabilitation of memory deficits.

The studies reviewed for this investigation did not report any information on
vocational outcomes following cognitive rehabilitation interventions as most of the
studies reviewed focused on cognitive rehabilitation interventions in addressing memory,
attention, and socio-behavioral deficits following TBI. It appears that studies need to be
done to explore the relationship between improvement in measures of memory, attention,
and socio-behavioral skills and the individual’s vocational outcome. However, based
upon a review of the literature cognitive rehabilitation intervention is performed on areas
of memory, attention, socio-behavioral deficits, and visuospatial deﬁcits in order to
improve functioning in these areas which ultimately will improve quality of life for these
individuals.

Based upon the literature, the most cited reasons for the failure to return to work
are the cognitive impairments (deficits in attention, and deficits in memory), socio-
behavioral deficits (problems with dishinibition, lack of awareness), and unrealistic
expectations concerning the kind of employment the individual is capable of doing. Many
studies have not addressed premorbid factors (education, type of employment, etc.) and
age of accident as being significant factors in the return to work process following an

acquired TBI. In fact, several authors (Lishman, 1978; & Grifﬁth, 1983) have argued

174

that the residual cognitive, emotional, and behavioral sequelae greatly exceed the
physical as the cause of long-term vocational difficulties. In addition, other studies have
shown that memory problems, changes in personality, loss of emotional control, and
problems in concentration posed the greatest barriers to return to premorbid status for
individuals with TBI (Thomsen, 1984 & Van Zomeren, 1985). In conclusion, although
the studies did not provide enough data to compute the statistical analysis on variables
such as age at time of accident, socio-economic status and ethnic background, it can be
assumed based upon the literature that the impact on vocational outcomes is more
associated with attention, memory and socio-behavioral deﬁcits.
Summary of Meta Analysis Study

This investigation was initiated because of my interest in TBI. Moreover, it came
to light as a result of interest in helping individuals with TBI return to work or obtain
employment within the community in which they reside. Additionally, there were a few
presumptive reasons in completing a meta analysis on cognitive rehabilitation
interventions with individuals with TBI. It appears from reading the literature as well as
working in the ﬁeld of brain injury rehabilitation, cognitive rehabilitation intervention as
a strategy has gained prominence in the ﬁeld as the most effective tool in helping
individuals with TBI improve their memory, attention, and socio-behavioral deﬁcits. As
such, having reviewed the data, it is very surprising that of all the studies reviewed, only
217 studies, 120 representing cognitive rehabilitation of memory deﬁcits, 67 representing
cognitive rehabilitation of attention deﬁcits, and 30 representing remediation of socio-
behavioral deﬁcits met the inclusion criteria and thus represent the empirical basis for

supporting the effectiveness of cognitive rehabilitation intervention. This may be

175

sufficient studies for this investigation, in fact it appears to be the most comprehensive
study to date, however this does not appear to be an overwhelming amount of studies to
support the empirical validity of cognitive rehabilitation. When one considers the
importance of cognitive rehabilitation interventions in the remediation of memory,
attention, and socio-behavioral deficits and the importance in improving the quality of
life of individuals with TBI, it is frustrating that more attention isn’t paid to the type(s) of
intervention being used, the areas of deﬁcit being examined and signiﬁcant variables
being reported.

In terms of strength(s) of this study, the length of time comes to mind. It took
approximately 4 years for this investigation to conclude. During this time, approximately
465 articles were reviewed, which is extensive. The studies were selected through an
inclusionary criteria (see appendix), data collection was completed utilizing a coding
sheet (see appendix), and it was based upon solid research practice. In addition, the study
utilized a statistical analysis known as a meta-analysis as its instrument, and the results
were presented in an organized way starting with a descriptive analysis of the studies and
participants, followed by a statistical analysis. In terms of the deﬁnition of TBI this
investigation did not include studies where the participants might have had a stroke or a
tumor that may have led to the brain injury. Given the length of time it took to complete
this study and the breath of researched articles utilized, it seemed to be a good
representation of the literature on the topic of cognitive rehabilitation intervention in
individuals with memory, attention, and socio-behavioral deﬁcits following TBI.

With respect to limitations, several are noted: 1) cognitive rehabilitation

intervention is a constellation of procedures that is utilized in the remediation of memory,

176

attention, and socio-behavioral deficits among others. However, in the vast majority of
studies, there is no indication of what intervention strategy or strategies were employed;
2) many studies were excluded from this research because they did not provide adequate
statistical results that could be translated into the effect size statistics and or did not met
the inclusionary criteria as determined by the investigator; and 3) the vast majority of
studies used in this investigation are published studies. As such, this may account for
higher effect sizes than would be found in unpublished studies.
Summary of Cognitive Rehabilitation with Individuals with Memory,
Attention and Socio-behavioral Deﬁcits following TBI

This study has contributed to our understanding of cognitive rehabilitation
interventions with individuals with memory, attention, and socio-behavioral deﬁcits
following TBI. However, I believe that there are some areas that could benefit from
future research. Having had the opportunity to review a large body of literature on
cognitive rehabilitation intervention research, it is alarming that such a lack of
standardization exists in reporting the research as well as the obvious inconsistencies in
methodology by a significant number of researchers in reporting their ﬁndings. Although
inconsistencies in the literature were managed within this investigation to some extent, it
is still necessary for researchers to follow a standard protocol when presenting their
ﬁndings from research.
Deﬁnition Issues

There are also some inconsistencies in terms of deﬁning cognitive rehabilitation
and what system or systems are actually being measured. Many terms are used such as

cognitive retraining, cognitive remediation, etc. Whereas cognitive retraining is a

177

systematic attempt to improve the resultant intellectual deficits that interfere with the
processing of information at some level; cognitive rehabilitation is broader in scope since
the goal of rehabilitation is functional adaptation in daily life activities. Cognitive
rehabilitation requires not only identifying speciﬁc operational problems but also
determining how it is done, methodology, and strict adherence to training priorities
(Ryan, Short, & Weed, 1986). The authors further assert that one cannot train a function
and expect improved performance or compensation in daily activities without
determining the speciﬁc effects of the deﬁcit on other cognitive systems.

Methodological Issues

Research arguing for or against cognitive rehabilitation has suffered from great
variability in levels of severity of injury in individuals with TBI, use of non-standardized
test protocols, lack of controls, absence of uniform data deﬁning success or failure, lack
of adequate and consistent verification of performance, and an absence of reliable follow-
up over long periods.

In addition, it was noticeable that a large segment of the literature contained
single case studies but lacked between-group studies. Additionally, many of the single-
case studies did not present any signiﬁcant statistical data, but rather the results were very
descriptive in nature. In addition, many lack inadequate pretreatment baselines,
inadequate duration of interventions, and incongruity between training and assessment
tasks. It can be assumed that single-case design studies are easier to carry out since
between-group designs present a practical as well as an ethical challenge of assigning
participants to a non-treatment condition. However, if such a design could be done, it is

the best way of examining the independent effects of treatment and spontaneous recovery

178

on the effectiveness of cognitive rehabilitation interventions. Given the unreliability of
the available empirical evidence for cognitive rehabilitation intervention, it is not
unreasonable for researchers to assign participants to one or more experimental treatment
conditions. For example, the ﬁeld of speech therapy has published several studies using
between-group designs (Basso, 1987).

An important generalizability issue facing clinicians who treat individuals with
memory, attention, and socio-behavioral deficits is that even though a strategy may be
found useful in a clinic setting how does one account for whether this intervention will be
useful outside of the clinic setting. Although research indicates that persons with TBI
require more time than normal controls to learn cognitive tasks (Stanwood, 1986), many
of the studies reviewed included fewer than ﬁve treatment sessions.

Another problem facing therapists is the issue of compliance. There are very few
systematic studies of the relation of compliance by individuals with TBI in memory,
attention, and socio-behavioral improvement. Other methodological problems are related
to issues raised in reviewing the studies used in this investigation. As previously stated,
demonstrating the effectiveness of cognitive remediation on memory, attention, and
socio-behavioral deficits can be misleading when spontaneous recovery is occurring or
when other treatments are being implemented simultaneously.

In addition, the difficulty still exists of trying to tailor a speciﬁc form of
intervention to the individual specific problems or needs. Cognitive rehabilitation
intervention is a necessary and effective technique in the treatment of memory, attention,
and socio-behavioral deficits in individuals with TBI. However, empirical work regarding

the treatment implications and external validity needs to be further examined.

179

Additionally, the relation of the diagnostic categories to premorbid history needs to be
addressed. This would help clinicians to compare treatment within and across treatment
facilities.

Although the results from this investigation reveal that cognitive rehabilitation
intervention was significant in the remediation of memory, attention, and socio-
behavioral deficits, the noted methodological problems, the inconsistency of reporting of
variables by many researchers, and the lack of standardization of treatment interventions
greatly diminish the claim that cognitive rehabilitation is a valid treatment approach in
the remediation of memory, attention, and socio-behavioral deﬁcits for individuals with
TBI. This is not to say that cognitive rehabilitation is not valid and should be abandoned,
rather, it suggest that clinicians and researchers need to employ interventions and
treatment protocols that have been successful with TBI participants with similar deﬁcits
in order to evaluate treatment effectiveness and efficacy.

Future Research on Cognitive Rehabilitation with
Individuals with Memory, Attention, and Socio-behavioral
Deficits following TBI

Future research in the treatment of memory, attention, and socio-behavioral
deficits would beneﬁt from a greater understanding of spontaneous recovery as a normal
brain process. For example, with memory interventions the field would beneﬁt from a
greater understanding of the mechanisms, or molecular skills, involved in memory. In
addition, research evaluating cognitive interventions should specify the etiology of the
injury so that the degree of effectiveness of different treatment methods may be discerned

in relation to etiology. The degree of the impairment should be speciﬁed, and this

180

speciﬁcation should include level of performance on standardized and laboratory tasks as
well as the speciﬁcation of the degree of impairment in daily activities.

It has been hypothesized that reduction of deﬁcits in the areas of memory,
attention, and socio-behavioral deficits should generalize to related skills and activities of
daily living; however, this has not been adequately shown in many of the studies. As a
result of the variation of cognitive deﬁcits in individuals with TBI, several skills should
be assessed throughout treatment to evaluate the impact of cognitive rehabilitation on
related and unrelated tasks. Future research should also focus on training tasks and
outcome measures that reflect activities of daily living and vocational skills (Diller &
Ben-Yishay, 1987).

Based upon my experience as investigator of this study, I am proposing a few
questions that should assist researchers in developing a more standardized set of
guidelines for future research:

1) Who are the participants receiving the intervention? (diagnosis or etiology,
severity of injury, age of participants, level of education, pre-injury, etc.)

2) What comprises cognitive rehabilitation intervention? (focus and rationale,
treatment duration and frequency, treatment setting, providers, are
interventions personalized to match client skills and/or needs)

3) What are the outcomes of the intervention? (what measures suggest changes in
attention, memory, and socio-behavioral deﬁcits {psychometric tests}, are
changes in activity/participation, is the change clinically meaningful, can the

changes be generalized)

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4) Are there methodological concerns? (do other explanations exist for a given
outcome, are results exaggerated, study design, reliability and validity issues
addressed)

5) Are training tasks and outcome measures a reﬂection of activities of daily living
and vocational skills

Cognitive rehabilitation interventions present an holistic treatment approach when '
working with persons with TBI. This approach involves many different treatment
modalities, each focusing on a different deficit. As such, in order to have successful
outcomes, rehabilitation programs need to focus on remediation of the multiplicity of
deficits.

Because of the neurological and behavioral sequelae of persons with TBI, it can
have an effect on the replication of research as changes, spontaneous recovery and
practice effect may enhance individual skill level. Therefore, when conducting research,
one needs to distinguish between the neurobehavioral subtypes, and the severity of injury
as defined by the Glasgow Coma Scale in order to control for these variables. In addition,
researchers need to identify the type of injury, i.e., frontal lobe, etc., as persons with this
types of injury will experience different types of deﬁcits from those with parietal lobe
injuries. As such, future studies should report information regarding subject
characteristics. When such information is not present as was the case in numerous studies
used in this meta analysis, the ability to generalize becomes limited.

Finally, the hypothesis that providing cognitive rehabilitation to persons with TBI
will result in decreased deficits associated with memory, attention, and socio-behavioral

deficits has been supported through the statistical analysis used in this meta analytic

182

review. However, because persons with TBI differ in the range and extent of cognitive
deﬁcits, programs that incorporate a comprehensive or holistic approach will be better
able to evaluate the impact of this intervention on primary as well as secondary tasks. The
conclusion from many of the studies is that cognitive rehabilitation intervention is
statistically signiﬁcant in reducing deﬁcits associated with memory, attention, and socio-
behavioral changes following TBI. However, these studies do not provide any
information on these changes will affect activities of daily living and vocational skills.

In conclusion, the claims that using cognitive rehabilitation interventions to
remediate memory, attention, and socio-behavioral deﬁcits as a valid treatment approach
for persons with TBI, appears to be supported by this investigation. Cognitive
rehabilitation intervention is the most current and used strategy in the remediation of
memory, attention, and socio—behavioral deficits. There is research evidence that
cognitive rehabilitation is effective in improving memory, attention, and socio-behavioral
deﬁcits in persons with TBI. However redundant it may sound, more research is needed
to address the effects spontaneous recovery, multiple treatment effects, and the number of
practice tasks given have on outcomes. In addition, more research can increase our
understanding of the type of strategy that may offer the most promise as well as
determine more precise implementation procedures, e.g., the matching of strategies to
types of brain damage or the types of deﬁcits encountered.

This research set out to determine the effect of cognitive rehabilitation
intervention in the remediation of memory, attention, and socio-behavioral deﬁcits in
persons with TBI. In this regard, cognitive rehabilitation was supported as being

effective in reducing deﬁcits associated with impairment following a TBI. The next phase

183

is for practitioners to transcend research into practice as this is the only means of

enhancing the quality of life for individuals with TBI.

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APPENDIX

There are two parts to the Appendix: Part one contains Appendix A which is the sample
code sheet and Appendix B which contains the definitions used to extrapolate data from
the various studies that make up the data base of this investigation. The second part
contain Appendix C which is a summary of all the studies included in this investigation
for the remediation of memory, Appendix D which contains the studies used for the
remediation of attention, Appendix E which contains all of the studies used for the
remediation of socio-behavioral deficits, and Appendix F which are studies that were

reviewed but were excluded from this investigation.

185

APPENDIX A

THE CODING INSTRUMENT

Topic Targeted: Memory Attention Socio-behavioral

 

Code #2 Date: Author:

 

Article Title:

Source: Journal: Book: Dissertation:

Journal Title:

Sample:

N Mean Age

 

Educational Level Severity of Injury
Socio Economic Status Gender: Male Female

Race: White/Caucasian Black/African American

 

Hispanic Asian American

 

American Indian Other
Treatment Facility: Inpatient Setting Clinic
Other
Outcome Measure: Standardized Experimental Other
Type of Measure: Rating Scale Checklist Observation

Psychometric Interview

186

THE CODING INSTRUMENT CONTINUED

 

 

 

 

Effect Size:

No of ES

Type of Statistic: t-score F-score r-score
ES

Notes/Comments:

187

 

APPENDIX B
OPERATIONAL DEFINITIONS FOR THE ARTICLE REVIEW SHEET
. Study Number: An identification number was assigned to each study in the order
it was coded, starting with Number 1.
. Author(s): The principal investigator(s) of the study.
. Publication Year: The year noted on the manuscript was recorded. For studies
that appear in multiple forms, the year of the most extensive report was used.
. Publication Form: The study was classified according to the form in which it
was published: (a) journal article, (2) book, (3) dissertation based publication, (4)
unpublished dissertation.
. Sample Size: The sample size was recorded
. Mean Age of Subjects: The mean chronological age of the study participants was
recorded as (1) reported in the study, (2) approximated from data in the study, or
(3) not obtainable.
. Mean Educational Achievement Level of Subjects: The mean number of years
of formal education of the study participants was recorded as (1) reported in

study, (2) approximated from data in the study, or (3) not obtainable.

. Median Socio-economic Status of Subjects: Median socio-economic status of

study participants was recorded as (1) low SES, (2) middle SES, or (3) high SES.
In those cases where actual mean income was provided, the following categories
were used: low (below 12,000), middle ($12,000 - $40,000), and high (higher
than $40,000). Median socio-economic status of subjects was recorded as (1)

reported in the study, (2) approximated from data in the study, (3) not obtainable.

188

9.

10.

ll.

12.

13.

14.

Gender of Subjects: The percent of male and female participants in the sample
was recorded as (1) reported in the study, (2) approximated from data in the study,
(3) not obtainable.

Cultural/Racial Mix: The percent of African Americans, Asian Americans,
Hispanics, Native Americans, and White Americans in the sample was recorded
as (1) reported in the study, (2) approximated from data in the study, (3) not
obtainable.

Severity of Injury: The number of participants with mild, moderate or severe
brain injury was recorded as (1) reported in the study, (2) approximated from data
in the study, (3) not obtainable. In cases where the severity of injury is not given,
the investigator will try to determine severity of injury by the following: Glasgow
Coma Scale: GCS = 12-15 (mild), GCS =9-l2 (moderate), and GCS = 1-8
(severe)

Associated Variable: This category was designed to identify variables associated
with cognitive rehabilitation intervention of persons with TBI: (1) age; (2) gender;
(3) race; (4) educational attainment level; (5) socioeconomic status or income; (6)
severity of injury; (7) pre-injury employment status; (8) other.

Description of Associated Variable: A description of the associated variable and
any relevant information obtained in the study was recorded.

Study Quality: A numerical rating of the study quality will be assigned to each

study on the basis of the following criteria (adapted from Hembree, 1984).

189

a)

b)

C)

d)

6)

Problem Identiﬁcation: clear hypotheses or research questions (3), no
hypotheses or research questions but clear statement of purpose (2), none
of the aforementioned (1).

Population Description: description of demographic items, i.e., age,
gender, race, educational level, socio-economic status, employment level,
and marital status. Six to seven demographic items obtainable (3), three to
five items obtainable (2), less than three demographic items obtainable (1).
Sampling Procedure: random (3), partially random (2), non-random (1)
Conclusions: appropriate and tied to hypothesis, research questions, or
purpose (3); appropriate, but with digressions (2); inappropriate (1).

Data Analysis: appropriate methods with full reporting of results (3),
appropriate methods with partial reporting or some data missing (2),
inappropriate methods, mistakes, or much data missing (1).

Each criterion will be evaluated on a scale from 1-3 (where 1 is low and 3

is high).

15. Effect Size Determination: Article speciﬁes either the effect size or statistical

data on which to calculate the ES score.

16. Type of Statistics: Article gives statistic results in terms of t-score, f-score, r-

score, or (1 score.

190

APPENDIX C
LIST OF 120 STUDIES USED IN THE DATA ANALYSIS AND SYNTHESIS
OF COGNITIVE REHABILITATION OF MEMORY DEFICITS IN INDIVIDUALS
WITH TBI

Abreu, B. C., & Toglia, J. P. (1987). Cognitive rehabilitation: A model for occupational
therapy. American Journal of Occupational Therapy, 41(7), 439-448.

Annoni, J.M., Jenkins, D.G., & Williams, J. (1989). Four case reports illustrating the
contribution of intensive cognitive rehabilitation in patients neuropsychologically
handicapped as a result of brain damage. Disability Rehabilitation, 17(8):449-
455.

Batchelor, J ., Shores, E., Maroosszeky, J ., Sandanam, J ., & Lovarini, M. (1988).
Cognitive rehabilitation of severely head-injured patients using computer-assisted

and noncomputerized treatment techniques. Journal of Head Trauma
Rehabilitation, 3:78-83.

Benedict, R.H., & Wechsler, ES. (1992). Evaluation of memory retraining in patients
with traumatic brain injury: Two single-case experimental designs. Journal of
Head Trauma Rehabilitation, 7(4): 83-92.

Benedict, R., Brandt, J ., & Bergey, G. (1993). An attempt at memory retraining in
severe amnesia: an experimental single-case study. Neuropsychological
Rehabilitation, 3:37-51.

Ben Yishay, Y., Silver, S. M., Piasetsky, E., & Rattok, J. (1987). Relationship between
employability and vocational outcome after intensive holistic cognitive
rehabilitation. Journal of Head Trauma Rehabilitation, 2(1), 35-48.

Bergman, M. M. (1991). The necessity of a clinical perspective in the design of
computer prostheses. Journal of Head Trauma Rehabilitation, 6(2), 100—104.

Berg Ina, J ., Koning, H.M., & Deelman, BC. (1991). Long-term effects of memory
rehabilitation: A controlled study. Neuropsychological Rehabilitation, l(2):97-
1 1 1.

Boring, RH. (1988). Group format memory retraining: A program designed for an
empirical evaluation of the effectiveness of memory retraining. Paper presented
at the seventh annual conference of the National Head-Injury Foundation, Atlanta,
GA.

191

Bradley, V.A., Welch, J .L., Skilbeck, CE. (1993). Cognitive retraining using
microcomputers. Hove (UK): L. Erlbaum Associates

Bracy, O. L. (1995). Soft tools ’95. Fast addition. Journal of Cognitive Rehabilitation,
13(6), 26.

Bracy, O. L. (1995). Soft tools ’95. Trail trace 3D. Journal of Cognitive Rehabilitation,
13(4), 26.

Bracy, O. L. (1996). Soft tools ’96. . .Digit/symbol transfer. Journal of Cognitive
Rehabilitation, 14(3), 26-27.

Bracy, O. L. (1996). Soft tools ’96. . .Shapes in a row. Journal of Cognitive
Rehabilitation, 14(5), 26-27.

Bracy, O. L. (1996). Soft tools ‘96. Spell it. Journal of Cognitive Rehabilitation, 14(1),
26-27.

Bracy, O. L. (1995). Soft tools. . .Color match 3D. Journal of Cognitive Rehabilitation,
13(5), 26.

Bracy, O. L. (1994). 3D Tic-Tac-Toe. . .3D extension of the old game. Journal of
Cognitive Rehabilitation, 12(6), 26.

Bracy, O. L. (1991). Soft tools...Flasher. Cognitive Rehabilitation, 9(4), 38-41.

Burke, W.H., Zencius, A.H., Wesolowski, M.D., & Doubleday, F. (1991). Improving
executive function disorders in brain-injured clients. Brain Injury, 5(3), 241-252.

Burke, J .M., Danick, J.A., Bemis, B., & Durgin, C]. (1994). A process approach to
memory book training for neurological patients. Brain Injury, 8(1), 71-81.

Cancelliere, A.E., Moncuda, C., & Reid, D.T. (1991). Memory training to support
educational reintegration. Archives of Physical Medicine and Rehabilitation, 72,
148-151.

Chen, S. H., Thomas, J. D., Glueckauf, R. L., & Bracy, O. L. (1997). The effectiveness
of computer-assisted cognitive rehabilitation for persons with traumatic brain
injury. Brain Injury, 11(3), 197-209.

Cotman, A., & Sandman, C. (1997). Cognitive deficits and their remediation in the
homeless. Journal of Cognitive Rehabilitation, 15(1), 16-23.

Cowley, B. J ., Green, G., & Braunling-McMorrow, D. (1992). Using stimulus

equivalence procedures to teach name-face matching to adults with brain injuries.
Journal of Applied Behavior Analysis, 25(2), 461-475.

192

Cowley, B.J., Green, G., & Braunling-McMorrow, D. (1992). Journal of Applied
Behavior Analyst, 25(2), 461-75.

Crosson, B., & Buenning, W. (1984). An individualized memory retraining program
after closed head injury: a single case study. Journal of Clinical
Neuropsychology, 6, 287-301.

Daniel, M., Webster, J .S., & Scott, RR. (1986). Single-case analysis of the brain-
injured patient. The Behavior Therapist, 4, 71-75.

Dirette, D.K., Hinojosa, J ., & Carnevale, G]. (1999). Comparison of remedial and
compensatory interventions for adults with acquired brain injuries. Journal of

Head Trauma Rehabilitation, 14(6), 595-601.

Evans, J .J ., Wilson, BA. (1996). A memory group for individuals with brain injury.
Clinical Rehabilitation, 6:75-81.

Finset, A., Krogstad, J .M., Hansen, H., Berstad, J ., Haarberg, D., Kristansen, G.,
Saether, K., & Wang, MD. (1995). Team development and memory training in
traumatic brain injury rehabilitation: Two birds with one stone. Brain Injury, 9(5):

495-507.

Fluharty, G., Sellon, C., & Glassman, N. (1994). Optimizing outcome through therapy
and advocacy: a case study. Brain Injury, 8(8): 729-734.

Freeman, M.R., Mittenberg, W., Dicowden, M., & Bat-Ami, M. (1992). Executive and
compensatory memory retraining in traumatic brain injury. Brain Injury, 6(1):65-
70.

Furst, C. (1994). The memory derby: evaluating and remediating intention memory.
Cognitive Rehabilitation, May/Junez24-26.

Fussey, K., & Tyerrnan, AD. (1985). An exploration of memory retraining in
rehabilitation following closed head-injury. International Journal of
Rehabilitation Research, 8, 465-467.

Glisky, E.L., Schacter, D.L., Tulving, E. (1986a). Computer learning by memory-
impaired patients: Acquisition and retention of complex of knowledge.
Neuropsychologia, 24, 313-328.

Glisky, E.L., Schacter, D.L., & Tulving, E. (1986b). Learning and retention of

computer-related vocabulary in memory-impaired patients: Method of vanishing
cues. Journal of Clinical and Experimental Neuropsychology, 8, 292-312.

193

Godfrey, H.P., & Knight, R.G. (1988). Memory training and behavioral rehabilitation
of a severely head-injured adult. Archives of Physical Medicine and
Rehabilitation, 69(6):458-60.

Goldstein, G., McCue, M., & Turner, SM. (1988). An efﬁcacy study of memory
training for patients with closed head injury. Clinical Neuropsychology, 6:287-
301.

Goldstein, G., Beers, S.R., Longmore, S., & McCue, M. (1996). Efficacy of memory
training: a technological extension and replication. Clinical Neuropsychology,
10:66-72.

Goldstein, F.C., Levin, H.S., Boake, C., & Lohrey, J .H. (1990). Facilitation of memory
performance through induced semantic processing in survivors of severe closed-
head injury. Journal of Clinical Experimental Neuropsychology, 12(2): 286-300.

Hux, K., Reid, R., & Lugert, M. (1994). Self-instruction training following neurological
injury. Applied Cognitive Psychology, 8:259-271.

Johnson, P., Thomas, N ., & Shein, F. (1994). Modifying memory function: Use of a
computer to train mnemonic skills. British Journal of Clinical Psychology,
29(4):437-438.

Kemer, M.J., & Acker, M. (1985). Computer delivery of memory retraining with head
injured patients. Cognitive Rehabilitation, November/December: 26-31.

Kime, S.K., Lamb, D.G., & Wilson, BA. (1997). Use of a comprehensive programme
of external cueing to enhance procedural memory in a patient with dense amnesia.
Brain Injury, 10(1): 17-25.

Kirsch, N.L., Levin, S.P., Fallon-Krueger, M., & Jaros, LA. (1987). The
microcomputer as an “orthotic” device for patients with cognitive deﬁcits.
Journal of Head Trauma Rehabilitation, 2(4):77-86.

Kirsch, N.L., Levin, S.P., Lajiness-O’Neil, R., & Schnyder, M. (1992). Computer-
assisted interactive task guidance: facilitating the performance of a simulated
vocational task. Journal of Head Trauma Rehabilitation, 7(3): 13-25.

Laatsch, L. (1983). Development of a memory training program. Cognitive
Rehabilitation, 1: 15-18.

Lawson, M.J., & Rice, D.N. (1989). Effects of training in use of executive strategies on

a verbal memory problem resulting from closed head injury. Journal of Clinical
and Experimental Neuropsychology, 11:842-854.

194

Levinson, R. (1997). Tests, measurement, and technology. The Planning and Execution
Assistant and Trainer (PEAT). . .hand-held electronic calendar and address book

that features automatic cueing to start and stop daily activities. Journal of Head
Trauma Rehabilitation, 12(2), 85-91.

Lynch, W. (1986). Computer-assisted memory assessment and rehabilitation. Journal
of Head Trauma Rehabilitation, 1(3):78-80

Malcolm, C. (1997). Memory strategies for successful adults. Journal of Cognitive
Rehabilitation, 15(2):6-7.

Malec, F.A., Goldstein, G., & McCue, M. (1991). Predictors of memory training
success in patients with closed head injury. Neuropsychology, 5:29-34.

Malec, J ., & Questad, K. (1983). Rehabilitation of memory after crainocerebral trauma:
Case report. Archives of Physical and Medical Rehabilitation, 64, 436-438.

Malloy, M., Rand, B., & Brown, W. (1984). Memory retraining: a study of four cases.
Journal of Occupational Therapy, 31:20-26.

McClure, J ., Browning, T., Vantrease, C., & Barker, M. (1997). The iconic memory
skills of brain injury survivors before and after iconic memory skills training.
Journal of Cognitive Rehabilitation, 15(3):20-23.

McGuire, B.E., & Greenwood, RI. (1990). Effects of an intervention aimed at memory
on perceived burden and self-esteem after traumatic head injury. Clinical
Rehabilitation, 4(4):319-323.

Milders, M.V., Berg, I.J., & Deelman, B.G. (1995). Four-year follow-up of a controlled
memory training study in closed head injured patients. Neuropsychological
Rehabilitation, 5(3):223-238.

Milders, M., Deelman, B., & Berg, 1. (1998). Rehabilitation of memory for people’s
names. Memory, 6:21-36.

Parente, R. (1994). Effect of monetary incentives on performance after traumatic brain
injury. Neuropsychological Rehabilitation, 4(3): 198-203.

Patyk, M., Gaynor, 8., Kelly, J., & Ott, V. (1998). Touch-screen computerized
education for patients with brain injuries. Rehabilitation Nursing, 23(2), 84-87.

Prigatano, G.P., Amin, K., & Jaramillo, K. (1993). Memory performance and use of a
compensation after traumatic brain injury. Neuropsychological Rehabilitation,
3(1):53-62.

Purdy, M., & Neri, L. (1989). Computer-assisted cognitive rehabilitation in the home.

195

Cognitive Rehabilitation, 7(6), 34-38.

Raskin, S.A., Bewick, K.C., Malia, K.B., & Bennett, TL (1996). The efﬁcacy of
prospective memory training in two adults with brain injury. Journal of Head
Trauma Rehabilitation, 11(3):32-51.

Raskin, S.A., & Sohlberg, M.M. (1996). The efﬁcacy of prospective memory training
in two adults with brain injury. Journal of Head Trauma Rehabilitation, 11:32-
51.

Raymond, M. J., Bewick, K. C., Malia, K. B., & Bennett, T. L. (1996). A
comprehensive approach to memory rehabilitation following brain injury. Journal
of Cognitive Rehabilitation, 14(6), 18-23.

Richardson, J .T. (1995). The efficacy of imagery mnemonics in memory remediation.
Neuropsychologia, 33(1 1):1345-1357.

Ryan, R.M., Mahaffey, R., Engle, J ., Farrow, C., Cox, D., & Karzmark, P. (1994).
Efﬁcacy study of THINKable in attention and memory training of traumatically
head-injured patients. Brain Injury, 8: 3-14.

Ryan, T.V., & Ruff, RM. (1988). The efficacy of structured memory retraining in a
group comparison of head trauma patients. Archives of Clinical Neuropsychology,
3: 165-179.

Schacter, D.L., Rich, S.A., & Stampp, MS. (1985). Remediation of memory disorders:
experimental evaluation of the spaced retrieval technique. Journal of Clinical and
Experimental Neuropsychology, 7:79-96.

Scherzer, BR (1986). Rehabilitation following severe head trauma: results of a three-
year program. Archives of Physical Medicine and Rehabilitation, 67:366-374.

Schmitter-Edgecombe, M., Fahy, J .F., Whelan, J .P., & Long, C.J. (1995). Memory
remediation after severe closed head injury: Notebook training versus supportive
therapy. Journal of Consulting and Clinical Psychology, 63(3):484-489.

Sohlberg, M.M., & Mateer, CA. (1989). Training use of compensatory memory books:
A three stage behavioral approach. Journal of Clinical Experimental
Neuropsychology, 1 1(6):871-891.

Sohlberg, M.M., White, 0., Evans, E., & Mateer, C. (1992). Background and initial
case studies into the effects of prospective memory training. Brain Injury, 6(2):
129-138.

Sohlberg, M.M., White, 0., Evans, E., & Mateer, C. (1992a). An investigation of the
effects of prospective memory training. Brain Injury, 6(2):139-154.

196

Sohlberg, M. M., White, 0., Evans, E., & Mateer, C. (1992b). An investigation of the
effects of prospective memory training. Brain Injury, 6(2), 107-108.

Squires, E.J., Hunkin, N.M., Parking, A.J. (1996). Memory notebook training in a case
of severe amnesia: generalizing from paired associate learning to real life.
Neuropsychological Rehabilitation, 6:55-65.

Thoene, A.I., & Glisky, EL. (1995). Learning of name-face associations in memory
impaired patients: a comparison of different training procedures. Journal
International Neuropsychology and Sociology, 1:29-38.

Whyte, J. (1986). Outcome evaluation in the remediation of attention and memory
deﬁcits. Journal of Head Trauma Rehabilitation, 1(3):64-71.

Wilson, B. (1992). Recovery and compensatory strategies in head injured memory
impaired people several years after insult. Journal of Neurosurgery and
Psychiatry, 55(3): 177-180.

Wilson, B.A., Baddeley, A., Evans, J ., & Shiel, A. (1994). Errorless learning in the
rehabilitation of memory impaired people. Neuropsychological Rehabilitation,
4(3):307-326.

Wilson, B.A., & Evans, J .J . ((1996). Error-free learning in the rehabilitation of people
with memory impairments. Journal of Head Trauma Rehabilitation, 11(2): 54-64.

Wilson, B.A., Evans, J .J ., Emslic, H., & Malinek, V. (1997). Neurology, Neurosurgery
& Psychiatry, 63:113-115.

Zencius, A., Wesolowski, M.D., & Burke, W.H. (1990). A comparison of four memory
strategies with traumatically brain-injured clients. Brain Injury, 4(1):33-38.

Zhou, J., Chittum, R., Johnson, K., Poppen, R., Guercio, J ., & McMorrow, M.J. (1996).

The utilization of a game format to increase knowledge of residuals among people
with acquired brain injury. Journal of Head Trauma Rehabilitation, 11(1):51-61.

197

APPENDIX D
LIST OF 67 STUDIES USED IN THE DATA ANALYSIS AND SYNTHESIS
OF COGNITIVE REHABILITATION OF ATTENTION DEFICIT S IN INDIVIDUALS
WITH TBI

Baribeau, J., Ethier, M., & Braun, C. 11989). A neuropsychological assessment of
selective attention before and after cognitive remediation in patients with severe
closed head injury. Journal of Neurological Rehabilitation, 3:71-92.

Ben-Yishay, Y., Piasetsky, E.B., & Rattock, J. (1987). A systematic method for
ameliorating disorders in basic attention. In J .M. Meier, A.L. Benton, & L. Diller
(Eds.), Neuropsychological Rehabilitation (pp. 165-181). New York: Guilford
Press.

Bracy, O. L. (1995). Road Trip [sic]...software. . .the enclosed diskette. . .requires one to
read a map. Journal of Cognitive Rehabilitation, 13(1), 26.

Bracy, O. L. (1995). What’s the Word?. . .software. . .enclosed diskette. Journal of
Cognitive Rehabilitation, 13(2), 26.

Bracy, O. L. (1994). Cognitive functioning and rehabilitation. Journal of Head Trauma
Rehabilitation, 12(2), 12-16.

Bracy, O. L. (1992). Soft tools: 0’s and 1’s. Journal of Cognitive Rehabilitation, 10(6),
48-59.

Bracy, O. L. (1992). The card shark game. Journal of Cognitive Rehabilitation, 10(4), 51-
59.

Bracy, O. L. (1991). Soft tools. . .P’s & Q’s. Cognitive Rehabilitation, 9(5), 42-53.

Bracy, O. L. (1991). Soft tools. . .Paced cancellation task PCT. . .simultaneous multiple
attention SMA. Cognitive Rehabilitation, 9(6), 35-41.

Bracey, O. (1983). Computer based cognitive rehabilitation. Cognitive Rehabilitation,
1:7-18.

Bracey, O. (1982). A home-based cognitive rehabilitation program. An unpublished
manuscript available from Psychological Software Services, Indianapolis, IN.

Ethier, M., Baribeau, J .M., & Braun, CM. (1989). Computer-dispensed cognitive-
perceptual training of closed head injury patients after spontaneous recovery.
Canadian Journal of Rehabilitation, 327-16.

198

Ethier, M., Braun, C.M., & Baribeau, J .M. (1989). Computer-dispensed cognitive-
perceptual training of closed head injury patients after spontaneous recovery.
Study 1: speeded tasks. Canadian Journal of Rehabilitation, 2:223-233.

Finlayson, M.A., Alfano, D.P., & Sullivan, J.F. (1987). A neuropsychological approach

to cognitive remediation: microcomputer applications. Canadian Psychology,
28:180-190.

Gansler, D.A., & McCaffrey, R]. (1991). Remediation of chronic attention deﬁcits in

traumatic brain-injured patients. Archives of Clinical Neuropsychology, 6:335-
353.

Gauggel, S., & Niemann, T. (1996). Evaluation of a short-term computer-assisted
training programme for the remediation of attentional deﬁcits after brain injury: a
preliminary study. International Journal of Rehabilitation Research, 19(3):229-
239.

Gray, J .M., Robertson, 1., Pentland, B., & Anderson, S. (1992). Microcomputer-based
attentional retraining after brain damage: a randomized group controlled trial.
Neuropsychological Rehabilitation, 2297-1 15.

Gray, J .M., & Robertson, 1. (1989). Remediation of attentional difﬁculties following
brain injury: three experimental single case studies. Brain Injury, 3: 163-170.

Jarvis, P.E., & Jarvis, GP. (1990). A tool to assist in the serial testing of attention as a
means of monitoring the effectiveness of rehabilitation. Cognitive Rehabilitation,
9(4):20-23.

Kirsch, N. L., Levine, S. P., Fallon Krueger, M., & Jaros, L. A. (1987). Focus on clinical
research: The microcomputer as an “orthotic” device for patients with cognitive
deﬁcits. Journal of Head Trauma Rehabilitation, 2(4), 77-86.

Kirsch, N. L., Levine, S. P., Lajiness O’Neill, R., & Schnyder, M. (1992). Computer
assisted interactive task guidance: Facilitating the performance of a simulated
vocational task. Journal of Head Trauma Rehabilitation, 7(3), 13-25.

Lundgren, C. C., & Persechinom, E. L. (1986). Cognitive group: A treatment program for
head-injured adults. American Journal of Occupational Therapy, 40(6), 397-401.

Malec, J ., Jones, R., Rao, N., & Stubbs, K. (1984). Video game practice effects on
sustained attention in patients with craniocerebral trauma. Cognitive
Rehabilitation, 2: 18-23.

McAllister, S., Rundell, J., Parker, S., Ferguson, D., Miller, D., Lowman, V., et al.

(1990). Head injury re-entry program at Miami Valley Hospital. Cognitive
Rehabilitation, 8(1), 6-12.

199

McGuire, B. E., & Greenwood, R. J. (1990). Effects of an intervention aimed at memory
on perceived burden and self-esteem after traumatic head injury. Clinical
Rehabilitation, 4(4), 319—323.

Meghji, C., Lonneberg, E., Bridgman, E., Malcolm, C., & Brown Hall, B. (1995).
Practice makes perfect: An interdisciplinary community living skills group for
persons with brain injury. Journal of Cognitive Rehabilitation, 13(6), 4-14.

Niemann, H., Ruff, R.M., & Baser, CA. (1990). Computer assisted attention retraining
in head injured individuals: a controlled efficacy study of an out-patient program.
Journal of Consulting & Clinical Psychology, 58:811-817.

Novack, T.A., Caldwell, S.G., Duke, L.W., Bergquist, T.F., & Gage, RI. (1996).
Focused versus unstructured intervention for attention deﬁcits after traumatic
brain injury. Journal of Head Trauma Rehabilitation, 11(3):52-60.

Ponsford, J .L., & Kinsella, G. (1988). Evaluation of a remedial programme for attentional
deﬁcits following closed head injury. Journal of Clinical Experimental
Neuropsychology, 10(6):693-708.

Purdy, M., & Neri, L. (1989). Computer-assisted cognitive rehabilitation in the home.
Cognitive Rehabilitation, 7(6):34—38.

Ruff, R.M., baser, C.A., & Johnson, J .W. (1989). Neuropsychological rehabilitation: an
experiemental study with head injured patients. Journal of Head trauma
Rehabilitation, 4(3):20-36.

Rugg, M.D., Pickles, C.D., Potter, D.D., Doyle, M.C., Pentland, B., & Roberts, RC.
(1993). Cognitive brain potentials in a three-stimulus auditory “oddball” task after
closed head injury. Neuropsychologia, 31:373-393.

Schwentor, D. (1993). Using video-based training with individuals with traumatic brain
injury. Journal of Cognitive Rehabilitation, 11(3):26-30.

Shum, D.H., McFarland, K.A., & Bain, J .D. (1990). Construct validity of eight tests of
attention: comparison of normal and closed head injured subjects. Clinical
Neuropsychology, 4: 151-162.

Sivak, M., Hill, C.S., & Olsen, PL. (1984). Computerized video tasks as training
techniques for driving-related perceptual deﬁcits of persons with brain damage: a
pilot evaluation. International Journal of Rehabilitation Research, 7:389-398.

Sohlberg, M.M., & Mateer, CA. (1987). Effectiveness of an attentional training program.
Journal of Clinical and Experimental Neur0psychology, 9:117-130.

200

Stanwood, J .K. (1986). An evaluation of video performance tasks in the cognitive
retraining of adults with closed head injuries. Unpublished doctoral dissertation,
Arizona State University, Temple, AZ.

Strache, W. (1987). Effectiveness of two modes of training to overcome deﬁcits of
concentration. International Journal of Rehabilitation Research, 10 Supplement
5:1418-1518.

Sturm, W., Wilmes, K., & Orgass, B. (1997). Do speciﬁc attention deﬁcits need speciﬁc
training? Neuropsychological Rehabilitation, 7281-103.

Sturm, W., Hartje, W., Orgass, B., & Willmess, K. (1993). Computer assisted
rehabilitation of attention impairments. In Stachowiak, F., ed. Developments in
the Assessment and Rehabilitation of Brain-damaged Patients. Tubingen,
Germany: Narr.

Stuss, D.T., Stethem, L.L., Hugeholtz, H., Picton, T., Pivik, J ., & Richard, M.T. (1989).
Reaction time after head injury: fatigue, divided and focused attention, and

consistency of performance. Journal of Neurology, Neurosurgery, and Psychiatry,
52:742-748.

Weber, A.M. (1990). A practical clinical approach to understanding and treating
attentional problems. Journal of Head Trauma Rehabilitation, 5(1):73-85.

Webster, J .S., & Scott, RR. (1983). The effects of self-instructional training on
attentional deﬁcits following head injury. Clinical Neuropsychology, 5:69-74.

Wilson, B., & Robertson, I.H. (1992). A home base intervention for attentional slips
during reading following head injury. a single case study. Neuropsychological
Rehabilitation, 2: 193-205.

Wood, R.L., & Fussey, I. (1987). Computer-assisted cognitive retraining: a controlled
study. International Disability Studies, 9: 149-153.

Wood, R.L. (1986). Rehabilitation of patients with disorders of attention. Journal of
Head Trauma Rehabilitation, 1:43-53.

201

APPENDIX E
LIST OF 30 STUDIES USED IN THE DATA ANALYSIS AND SYNTHESIS
OF COGNITIVE REHABILITATION OF SOCIO-BEHAVIORAL DEFICITS IN
INDIVIDUALS WITH TBI

Alderman, N., & Knight, C. (1997). The effectiveness of DRL in the management and
treatment of severe behavior disorders following brain injury. Brain Injury, 11(2),
79-101.

Ansell, B. J. (1993). Slow-to-recover patients: Improvement to rehabilitation readiness.
Joumal of Head Trauma Rehabilitation, 8(3), 88-98.

Chittum, W. R., Johnson, K., Chittum, J. M., Guerico, J. M., & McMorrow, M. J. (1996).
Road to awareness: An individualized training package for increasing knowledge
and compensation of personal deﬁcits in persons with acquired brain injury. Brain
Injury, 10(10),763-776.

Crosson, B., Barco, P.P., Velozo, C.A., Bolesta, M.M., Cooper, P.V., Werts, D., &
Brobeck, TC. (1989). Awareness and compensation in postacute head injury
rehabilitation. Journal of Head Trauma Rehabilitation, 16(5):611-627.

DiCesare, A., Parente, R., & Anderson Parente J. (1990). Personality change after

traumatic brain injury: Problems and solutions. Cognitive Rehabilitation, 8(2), 14-
18.

Dikmen, S. 8., Ross, B. L., Machamer, J. E., & Temkin, N. R. (1995). One year
psychosocial outcome in head injury. Joumal of International Neuropsychology
and Sociology, 1(1), 67-77.

Dikmen, S., Machamer, J ., & Temkin, N. (1993). Psychosocial outcome in patients with
moderate to severe head injury: 2-year follow-up. Brain Injury, 7(2), 113-124.

Fryer, L. J ., & Haffey, W. J. (1987). Cognitive rehabilitation and community

readaptation: Outcomes from two program models. Journal of Head Trauma
Rehabilitation, 2(3), 51-63.

Garner, R. L. (1996). The NAT model: Factors in neuropsychological art therapy.
American Journal of Art Therapy, 34(4), 107-111.

Hart, T., & Jacobs, HE. (1993). Rehabilitation and management of behavioral

disturbances following frontal lobe injury. Journal of Head Trauma
Rehabilitation, 8(1): 1-12.

202

Hinkeldey, N.S., & Corrigan, J .D. (1990). The structure of head-injured patients’
neurobehavioral complaints: a preliminary study. Brain Injury, 4:115-133.

Klonoff, P.S., O’Brien, K.P., Prigatano, G.P., Chiapello, DA. (1989). Cognitive
retraining after traumatic brain injury and its role in facilitating awareness.
Journal of Head Trauma Rehabilitation, 4(3):37-45.

Laatsch, L., Jobe, T., Sychra, J ., Lin, Q., & Blend, M. (1997). Impact of cognitive
rehabilitation therapy on neuropsychological impairments as measured by brain
perfusion SPECT: a longitudinal study. Brain Injury, 11(12):851-863.

Levine, B., Dawson, D., Boutet, I., Schwartz, M., & Stuss, D. (2000). Assessment of
strategic self-regulation in traumatic brain injury: its relationship to injury severity
and psychosocial outcomes. Neuropsychology, 14(4):491-500.

McAllister, S., Rundell, J ., Parker, 8., Ferguson, D., Miller, D., Lowman, V., (1990).
Head injury re-entry program at Miami Valley Hospital. Cognitive Rehabilitation,
8(1), 6-12.

Miller, L. (1989). Neuropsychology, personality, and substance abuse: Implications for
head injury rehabilitation. Cognitive Rehabilitation, 7(5):26-31.

Miller, L. (1990). Major syndromes of aggressive behavior following head injury.
Cognitive Rehabilitation, 8(6):406-414.

Ruff, R. M., & Niemann, H. (1990). Cognitive rehabilitation versus day treatment in
head-injured adults: Is there an impact on emotional and psychosocial
adjustment? Brain Injury, 4(4), 339-347.

Sachs, P. R., Bell, E., Berger, M., & Carroll R. C. (1986). A six-factor model for
treatment planning and cognitive retraining of the traumatically head -injured
adult. Cognitive Rehabilitation, 4(1), 26-30.

Schwartz, SM. (1995). Adults with traumatic brain injury: three case studies of cognitive
rehabilitation in the home setting. American Journal of Occupational Therapy,
49(7):655-667.

Sherer, M., Oden, K., Bergloff, P., Levin, E., & High, W. M., Jr. (1998). Assessment and
treatment of impaired awareness after brain injury: Implications for community
re-integration. Neurorehabilitation, 10(1), 25-37.

Simpson, G., Tate, R., Ferry, K., Hodgkinson, A., & Blaszczynski, A. (2001). Social,
neuroradiologic, medical, and neuropsychologic correlates of sexually aberrant

behavior after traumatic brain injury: a controlled study. Journal of Head Trauma
Rehabilitation, 16(6):556—572.

203

Slade, C., & Burns, R. (1992). Cognitive rehabilitation at a retail work site. Joumal of
Cognitive Rehabilitation, 10(3), 10-13.

Sohlberg, M.M., Mateer, C.A., Stuss, D.T. (1993). Contemporary approaches to the
management of executive control dysfunction. Journal of Head Trauma
Rehabilitation, 18:45-56.

Turkstra, L., & Flora, T. (2002). Compensating for executive function impairments after
TBI: a single case study of functional intervention. Journal of Communication
Disorders, 35:467-482.

Youngson, H.A., & Alderman, N. (1994). Fear of incontinence and its effects on a
community-based rehabilitation programme after severe brain injury: successful
remediation of escape behavior using behavior modiﬁcation. Brain Injury,
4(1):33-38.

Zencius, A., Wesolowski, M. D., Burke, W. H., & Hough, S. (1990). Managing
hypersexual disorders in brain-injured clients. Brain Injury, 4(2), 175-181.

Zencius, A. H., Lane, I., & Wesolowski, M. D. (1991). Assessing and treating non-
compliance in brain-injured clients. Brain Injury, 5(4), 369-374.

204

APPENDIX F

LIST OF STUDIES REVIEWED BUT WERE NOT USED IN THE DATA ANALYSIS
AND SYNTHESIS

Abrams, D., Barker, L. T., Haffey, W., & Nelson, H. (1993). The economics of return to
work for survivors of traumatic brain injury: Vocational services are worth the
investment. Journal of Head Trauma Rehabilitation, 8(4), 59-76.

Ackerman, R. J ., & Banks, M. E. (1990). Computers and ethical treatment for brain-
injured patients. Social Science Computer Review, 8(1), 83-95.

Adamovich, B. B., Henderson, J. A., & Auerbach, S. (1991). Cognitive rehabilitation of
closed head injured patients: A dynamic approach. Austin, TX: PRO-ED.

Alderman, N. (1996). Central executive deficit and response to operant conditioning
methods. Neuropsychological Rehabilitation, 6(3), 161-186.

Allman, P. (1992). Drug treatment of emotionalism following brain damage. Journal of
Rehabilitation and Social Medicine, 85(7), 423-424.

Andrews, T. K., Rose, F.D., & Johnson, D. A. (1998). Social and behavioural effects of
traumatic brain injury in children. Brain Injury, 12(2),133-138.

Arokiasamy, C. V., & Millington, M. J. (1994). The many stakeholders in return to work.
Neurorehabilitation, 4(1), 45-52.

Ashley, M. J. (1995). Traumatic brain injury rehabilitation. Boca Raton, FL: CRC Press.

Ashley, M. J ., & Krych, D. K. Cognitive disorders: Diagnosis and treatment in the TBI
patient. In M. J. Ashley & D. K. Krych (Eds.), Traumatic brain injury
rehabilitation (pp. 289-318). Boca Raton, FL: CRC Press.

Ashley, M. J., Krych, D. K., & Lehr, R. P. (1992). Cost/beneﬁt analysis for post-acute
rehabilitation of traumatically brain-injured patient. Journal of Insurance
Medicine, 24, 186-192.

Ashley, M. J ., Persel, C. S., Clark, M. C., & Krych, D. K. (1997). Long-term follow-up of
post-acute traumatic brain injury rehabilitation: A statistical analysis to test for
stability and predictability of outcome. Brain Injury, 11(9), 677 -690.

Asikainen,1., Kaste, M., & Sama, S. (1996). Patients with traumatic brain injury referred

to a rehabilitation and re-employment programme: Social and professional
outcome for 508 Finnish patients 5 or more years after injury. Brain Injury,

205

10(12), 883-899.

Auerbach, V., & Jann, B. (1991). Ethicolegal issues in pharrnacotherapy for
neurorehabilitation. Neurorehabilitation, 1(1), 58-63.

Barry, R, & O’Leary, J. (1989). Roles of the psychologist on a traumatic brain injury
rehabilitation team. [Special issue]. Traumatic brain injury rehabilitation.
Rehabilitation Psychology, 34(2), 83-90.

Bell, K. R., & Cardenas, D. C. (1995). New frontiers of neuropharmacologic treatment of
brain injury agitation. Neurorehabilitation, 5(3), 233-244.

Bellus, S. B., Stewart, D., Vergo, J. G., Kost, P. P., Grace, J ., & Barkstrom, S. R. (1996).
The use of lithium in the treatment of aggressive behaviors with two-brain-injured
individuals in a state psychiatric hospital. Brain Injury, 10(11), 849-860.

Ben-Yishay, Y, & Diller, L. (1993). Cognitive remediation in traumatic brain injury:
Update and issues. Archives of Physical Medical Rehabilitation, 74(2), 204-213.

Bergquist, T. F., Boll, T. J ., Corrigan, J. D., Harley, J. P., Malec, j. R, & Millis, S. R., et
al. (1994). Neuropsychological rehabilitation: Proceedings of a consensus
conference. Journal of Head Trauma Rehabilitation, 9(4), 50-61.

Bergquist, T. F., & Malec, J. F. (1997). Psychology: Current practice and training issues
in the treatment of cognitive dysfunction. Neurorehabilitation, 8(1), 49-56.

Berrol, C. (1990). Dance/movement therapy in head injury rehabilitation. Brain Injury,
4(3), 257-265.

Bewick, K. C., Raymond, M. J ., Malia, K. B., & Bennett, T. L. (1995). Metacognition as
the ultimate executive function: Techniques and tasks to facilitate executive
function. Neurorehabilitation, 5(4), 367-375.

Blackerby, F. A. (1990). A treatment model for sexuality disturbance following brain
injury. Journal of Head Trauma Rehabilitation, 5(2), 73-82.

Blosser, J., & Pearson, S. (1997). Transition coordination for students with brain injury:
A challenge schools can meet. Journal of Head Trauma Rehabilitation, 12(2), 21-
31.

Boake, C. (1989). A history of cognitive rehabilitation of head-injured patients, 1915-
1980. Journal of Head Trauma Rehabilitation, 4(3), 1-8.

Bogner, J. A., Corrigan, J. D., Spafford, D. E, & Lamb-Hart, G. L. (1997). Integrating

substance abuse treatment and vocational rehabilitation after traumatic brain
injury. Journal of Head Trauma Rehabilitation, 12(5), 57-71.

206

Bomstein, R. A., Miller, H. B., & Van Schoor, T. (1988). Emotional adjustment in
compensated head injury patients. Neurosurgery, 23(5), 622-627.

Bracy, O. L. (1994). To do therapy or not do therapy — That is part of the question.
Journal of Cognitive Rehabilitation, 12(4), 2-3.

Bracy, O. L. (1995). From the editor. . .free Soft Tools diskette with each issue. Journal of
Cognitive Rehabilitation, l3 (1), 2.

Bracy, O. L. (1992). Soft tools. Journal of Cognitive Rehabilitation, 10(5), 49-59.

Bufﬁngton, A. L., & Malec, J. F. (1997). The vocational rehabilitation continuum:

Maximizing outcomes through bridging the gap from hospital to community-
based services. Journal of Head Trauma Rehabilitation, 12(5), 10-13.

Burke, W. H., Wesolowski, M. D., & Guth, M. L. (1988). Comprehensive head injury
rehabilitation: An outcome evaluation. Brain Injury, 2(4), 313-322.

Carlson, H. B., & Buckwald, M. B. (1993). Vocational communication group treatment
in an outpatient head injury facility. Brain Injury, 7(2), 183-187.

Chapman, S. B., Levin, H. S., Matejka, J ., Harward, H., & Kufera, J. A. (1995).
Discourse ability in children with brain injury: Correlations with psychosocial,

linguistic, and cognitive factors. Journal of Head Trauma Rehabilitation, 10(5),
36-54.

Christensen, A. L. (1992). Outpatient management and outcome in relation to work in
traumatic brain injury patients. Scandinavian Journal of Rehabilitation of Medical
Supplement, 26, 34-42.

Christensen, A. L., & Uzzell, B. P. (1994). Brain injury and neuropsychological
rehabilitation: International perspectives. Hillsdale, NJ: Lawrence Erhlbaum
Associates.

Cicerone, K. D. (1997). Cognitive rehabilitation: Learning from experience and planning
ahead. Neurorehabilitation, 8(1), 13-19.

Cifu, D. X., Keyser-Marcus, L., Lopez, E., Wehman, P., Kreutzer, J. S., Englander, J. et
al. (1997). Acute predictors of successful return to work 1 year after traumatic

brain injury: A multicenter analysis. Archives of Physical and Medical
Rehabilitation, 78(2), 125-131.

Coelho, C. A., DeRuyter, F., & Stein, M. (1996). Treatment efficacy: Cognitive-

communication disorders resulting from traumatic brain injury in adults. Journal
of Speech and Hearing, 39(5), 5-17.

207

Cohen, S. B. (1986). Educational reintegration and programming for children with head
injuries. Journal of Head Trauma Rehabilitation, 1(4), 22-29.

Conder, R. Evans, D. Faulkner, P., Henley, K. Dreutzer, J. Lent, B., et al. (1988). An
interdisciplinary programme for cognitive rehabilitation. Brain Injury, 2(4), 365-
385.

Conder, R. L. (1989). Recommendations for clinical and research evaluation of
vocational re-entry programmes for survivors of traumatic brain injury. Brain
Injury, 3(1), 1-4.

Corrigan, J. D., Lamb-Hart, G. L., & Rust, E. (1995). A programme of intervention for
substance abuse following traumatic brain injury. Brain Injury, 9(3), 221-236.

Corthell, D. W. (1993). Employment outcomes for persons with acquired brain injury.
Washington, DC: National Institute on Disability and Rehabilitation Research.

Crepeau, F., & Scherzer, P. (1993). Predictors and indicators of work status after
traumatic brain injury: A meta-analysis. Neuropsychology and Rehabilitation,
3(1), 5-35.

Crosson, B., Barco P. P., Velozo, C. A., Bolesta, M. M. Cooper, P. V., Wertz, D., et al.
(1989). Awareness and compensation in postacute head injury rehabilitation.
Journal of Head Trauma Rehabilitation, 4(3), 46-54.

Crowley, J. A., & Miles, M. A. (1991). Cognitive remediation in pediatric head injury: A
case study. Journal of Pediatric Psychology, 16(5), 611-627.

Curl, R. M., Fraser, R. T., Cook, R. G., & Clemmons, D. (1996). Traumatic brain injury
vocational rehabilitation: Preliminary ﬁndings for the coworker as trainer project.
Journal of Head Trauma Rehabilitation, 11(1), 75-85.

Dawson, D. R., & Chipman, M. (1995). The disablement experience by traumatically
brain-injured adults living in the community. Brain Injury, 9(4), 339-353.

Deaton, A. V., Martelli, M. F., Pickelman, H., West, D. D., & Kreutzer, J. S. (1992).
IBM-based cognitive rehabilitation software: Closing the gap. Journal of
Cognitive Rehabilitation, 10(6), 20-36.

DeMolfetto, J. (1995). From the patient’s point of view. Recovery from head injury: A
life long process being reborn. Journal of Cognitive Rehabilitation, 13(4), 4-5.

Deshpande, S. A., Millis, S. R., Reeder, K. P., Fuerst, D., & Ricker, J. H. (1996). Verbal

learning subtypes in traumatic brain injury: A replication. Journal of Clinical
Experimental Neuropsychology, 18(6), 836-842.

208

D’Esposito, M. D., & Alexander, M. P. (1995) The clinical proﬁles, recovery, and
rehabilitation of memory disorders. Neurorehabilitation, 5(2), 141-159.

Devany, C. W., Kreutzer, J. S., Halberstadt, L. J ., & West, D. D. (1991). Referrals for
supported employment after brain injury: Neuropsychological, behavioral, and
emotional characteristics. Journal of Head Trauma Rehabilitation, 6(3), 59-70.

Devany Serio, C., & Devens, M. (1994). Employment problems following traumatic
brain injury: Families assess the causes. Neurorehabilitation, 4(1), 53-57.

Dikengil, A., King, C., & Monda, D. (1992). Communication functional skills group: An
integrated group therapy approach to head injury rehabilitation. Journal of
Cognitive Rehabilitation, 10(4), 28-31.

Dikengil, A., Lowry, M., & Delgado, P. (1993). An interdisciplinary group treatment for
the severely brain-injured patient: Participation by four disciplines. Journal of
Cognitive Rehabilitation, 11(1), 20-24.

Dikmen, S. S., Temkin, N. R., Machamer, J. E., Holubkov, A. L., Fraser, R. T., & Winn,
H. R. (1994). Employment following traumatic head injuries. Archives of
Neurology. 51(2), 177-186.

Direnfeld, G. (1996). Brain injury: Reweaving the spider’s web. Journal of Cognitive
Rehabilitation, 14(5), 6-7.

Doman, G, Wilkinson, R. Dimancescu, M. D., & Pelligra R. (1993). The effect of intense
multi-sensory stimulation on coma arousal and recovery [Special issue]. Coma

and the persistent vegetative state. Neuropsychological Rehabilitation, 3(2), 203-
212.

Dombovy, M. L., & Olek, A. C. (1997) Recovery and rehabilitation following traumatic
brain injury. Brain Injury, 11(5), 305-318.

Donders, J. (1992). Premorbid behavioral and psychosocial adjustment of children with
traumatic brain injury. Journal of Abnormal Child Psychology, 20(3), 233-246.

Donders, J ., & Ballard, E. (1996). Psychological adjustment characteristics of children
before and after moderate to severe traumatic brain injury. Journal of Head
Trauma Rehabilitation, 11(3), 67-73.

Dougherty, P. M., & Randomski, M. V. (1993). The cognitive rehabilitation workbook: A
dynamic assessment approach for adults with brain injury (2’”1 ed.). Gaithersburg,
MD: Aspen Publishers.

Dryovage, J., & Seidman, K. (1992). Interdisciplinary approach to community

209

reintegration. Journal of Cognitive Rehabilitation, 10(4), 12-21.

Executive function disorders. (1993). Journal of Head Trauma Rehabilitation, 8(1), 1-
120.

Ezrachi, 0., Ben Yishay, Y., Kay, T., Diller, L., & Rattok, J. (1991). Predicting
employment in traumatic brain injury following neuropsychological
rehabilitation. Journal of Head Trauma Rehabilitation, 6(3), 71-84.

Fines, L., & Nichols, D. (1994). An evaluation of a twelve week recreational kayak
program: Effects on self-concept, leisure satisfaction and leisure attitude of adults
with traumatic brain injuries. Journal of Cognitive Rehabilitation, 12(5), 10-15.

Fluharty, G. (1993). Use of an electronic dictionary to compensate for surface
dysgraphia. Journal of Cognitive Rehabilitation, 11(1), 28-30.

Fraser, R. T. (1991). Vocational evaluation. Journal of Head Trauma Rehabilitation,
6(3), 46-58.

Fraser, R. T., Cook, R., Clemmons, D. C., & Curl, R. H. (1997). Work access in
_ traumatic brain injury rehabilitation: A perspective for the physiatrist and
rehabilitation team. Physical and Medical Rehabilitation Annals of North
America, 8(2), 371-387.

Gianutsos, R. (1991). Cognitive rehabilitation: A neuropsychological specialty comes of
age. Brain Injury, 5(4), 353-368.

Gianutsos, R. (1992). The computer in cognitive rehabilitation: It’s not just a tool
anymore. Journal of Head Trauma Rehabilitation, 7(3), 26-35.

Gil, M., Cohen, M., Korn, C., & Groswasser, Z. (1996). Vocational outcome of aphasic
patients following severe traumatic brain injury. Brain Injury, 10(1), 39-45.

Godfrey, H. P., Bishara, S. N., Partridge, F. M., & Knight, R. G. (1993).
Neuropsychological impairment and return to work following sever closed head

injury: Implications for clinical management. New Zeeland Medical Journal,
106(960), 301-303.

Goodall, P., Lawyer, H. L., & Wehman, P. (1994). Vocational rehabilitation and
traumatic brain injury: A legislative and public policy perspective. Journal of
Head Trauma Rehabilitation, 9(2), 61-81.

Goodwin, R. E., & Bolton, D. P. (1991). Decision-making in cognitive rehabilitation: A
clinical model. Cognitive Rehabilitation, 9(4), 12-19.

Gordon, W. A., Hibbard, M. R., & Kreutzer, J. (1989) Cognitive remediation issues in

210

research and practice. Journal of Head Trauma Rehabilitation, 4(3), 76-84.

Gordon, W. A., Sliwinski, M., Echo, J ., McLoughlin, M., Sheerer, M. S., & Meili, T. E.
(1998). The beneﬁts of exercise in individuals with traumatic brain injury: A
retrospective study. Journal of Head Trauma Rehabilitation, 13(4), 58-67.

Groveman, A. M., Brown, E. W., & Miller, M. H. (1985). Moving toward common
ground: Utilizing Feurstein’s model in cognitive rehabilitation. Cognitive
Rehabilitation, 3(3), 28-30.

Guiilmette, T. J. (1997). Pocket guide to brain injury, cognitive, and neurobehavioral
rehabilitation. San Diego, CA: Singular Pub. Group.

Haffey, W. J. (1989). The assessment of clinical competency to consent to medical
rehabilitative interventions. Joumal of Head Trauma Rehabilitation, 4(1), 43-56.

Haffey, W. J ., & Abrams, D. L. (1991). Employment outcomes for participants in a brain
injury work reentry program: Preliminary ﬁndings. Journal of Head Trauma
Rehabilitation, 6(3), 24-34.

Haffey, W. J ., & Lewis, F. D. (1989). Programming for occupational outcomes following
traumatic brain injury [Special issue]. Traumatic brain injury rehabilitation.
Rehabilitation Psychology, 34(2), 147-158.

Hanson, C. S., Shechtman, O. Foss, J. J ., & Krauss-Hooker, A. (1997). Occupational
therapy: Current practice and training issues in the treatment of cognitive
dysfunction. Neurorehabilitation, 8(1), 31-41.

Harrell, M. (1992). Cognitive rehabilitation of memory: A practical guide. Gaithersburg:
MD: Aspen Publishers.

Hartley, L. L. (1995). Cognitive-communicative abilities following brain injury: A
functional approach. San Diego, CA: Singular Pub. Group.

Heyer, N. J ., & Franklin, G. M. (1994). Work related traumatic brain injury in
Washington State, 1988 through 1990. American Journal of Public Health, 84(7),
1 106-1 109.

Ho, M. R., & Bennett, T. L. (1997). Efﬁcacy of neuropsychological rehabilitation for
mild-moderate traumatic brain injury. Archives of Clinical Neuropsychology,
12(1), 1-11.

Hoepfer, M. (1996). Computers help reprogram injured brains. Physical Medicine, 99(4),
34-36.

Hogarty, G. E. & Glesher, S. (1992). Cognitive remediation in schizophrenia: Proceed

211

with caution! Schizophrenia Bulletin, 18(1), 51-57.

Huber, L., & Edelberg, B. (1993). A community integration model of head injury
rehabilitation. Journal of Cognitive Rehabilitation, 11(2), 22-26.

Iacarino, J. (1997). The speech-language pathologist on the cognitive rehabilitation team:
Current training and practice issues. Neurorehabilitation, 8(1), 43-48.

Ip R. Y., Doman, J ., & Schentag, C. (1995). Traumatic brain injury: Factors predicting
return to work or school. Brain Injury, 9(5), 517-532.

Jacobs, H. E. (1997). The clubhouse: Addressing work-related behavioral challenges
through a supportive social community. Journal of Head Trauma Rehabilitation,
12(5), 14-27.

Jarvis, P. E. (1990). The importance of patient friendliness in CACR software and tips for
improving it. . .Computer assisted cognitive rehabilitation. Cognitive
Rehabilitation, 8(4), 24-28.

Jarvis, P. E., & Jarvis C. P. (1991). A tool to assist in the serial testing of attention as a

means of monitoring the effectiveness of rehabilitation. Cognitive Rehabilitation,
9(4), 20-23.

Johnson, D. A., Rose, F. D., Rushton, S., Pentland, B., & Attree, E. A. (1998). Virtual
reality: A new prosthesis for brain injury rehabilitation. Scott Medical Journal,
43(3), 81-83.

Johnson, P., Thomas, S. N. & Shein, F. (1994). Development of a computer-based
program for the remediation of cognitive communication skills in young people

with head injuries. Journal of Cognitive Rehabilitation, 12(4), 10-16.

Johnson, R. (1989). Employment after severe head injury: Do the Manpower Services
Commission schemes help? Brain Injury, 20(1), 5-9.

Johnson, R. (1998). How do people get back to work after severe head injury? A 10 year
follow-up study. Neuropsychological Rehabilitation, 8(1), 61-79.

Kay, T. (1993). Neuropsychological treatment of mild traumatic brain injury. Journal of
Head Trauma Rehabilitation, 8(3), 74-85.

King, T. (1993). Treatment of visual inattention using computerized overhead projection.
Journal of Cognitive Rehabilitation, 11(2), 32-35.

Kinney, LaPier, T. L., Sirotnak, N ., & Alexander, K. (1998). Aerobic exercise for a
patient with chronic multisystem impairments. Physical Therapy, 78(4), 417-424.

212

Kirsch, N. L., & Levine, S. P. (1992). Technology and head injury rehabilitation. Journal
of Head Trauma Rehabilitation, 7(3), vii-119.

Knox, R., & J utai, J. (1996). Music-based rehabilitation of attention following brain
injury. Canadian Journal of Rehabilitation, 9(3), 169-181.

Kolpan, K. I. (1987). Employment beneﬁts for the traumatic brain-injured. Journal of
Head Trauma Rehabilitation, 2(1), 81-82.

Kosciulek, J. F. (1991). The impact of traumatic brain injury on work adjustment
development. Vocational Evaluation and Work Adjustment Bulletin, 24(4), 137-
140.

Kraft, J. F., Schwab, K. A., Salazar, A. M., & Brown, H. R. (1993). Occupational and
educational achievements of head injured Vietnam veterans at 15 year follow-up.
Archives of Physical and Medical Rehabilitation, 74(6), 596-601.

Kregel, J ., Parent, W., & West, M. (1994). The impact of behavioral deﬁcits on
employment retention: An illustration from supported employment.
Neurorehabilitation, 4(1), 1-14.

Kreutzer, J. S., West, M., Sherron, P., Wehman, P. H., & Fry, R. (1992). Computer
technology in vocational rehabilitation. Journal of Head Trauma Rehabilitation,
7(3), 70-80.

LaMarche, J. A., Reed, L. K., Rich, M. A., Cash, A. W., Lucas, L. H., & Boll, T. J.
(1995). The interactive community-based model of vocational rehabilitation in
traumatic brain injuries. Journal of Head Trauma Rehabilitation, 10(4), 81-89.

Lash, M., & Scarpino, C. (1995). School reintegration for children with traumatic brain
injuries: Conﬂicts between medical and educational systems. Neurorehabilitation,
3(3), 13-25.

Lawler, K. A., & Terregino, C. A. (1996). Guidelines for evaluation and education of
adult patients with mild traumatic brain injuries in an acute care hospital setting.
Journal of Head Trauma Rehabilitation, 11(6), 18-28.

Leon Carrion, J. E. (1997). Neuropsychological rehabilitation: Fundamentals,
innovations, and directions. Delray Beach, FL: GR/St. Lucie Press.

Levine, S. P., Horstmann, H. M., & Kirsch N. L. (1992). Performance considerations for

people with cognitive impairment in accessing assistive technologies. Journal of
Head Trauma Rehabilitation, 7(3), 46-58.

Lynch, W. (1986). Adaptive devices for microcomputers. . .part 1. Journal of Head
Trauma Rehabilitation, 1(4), 80-82.

213

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Lynch, W. (1987). Adaptive devices for microcomputers. . .part 2. Journal of Head
Trauma Rehabilitation, 2(1), 79-80.

Lynch, W. (1986). Computer-assisted cognitive retraining. Journal of Head Trauma
Rehabilitation, 1(2), 77-78.

Lynch, W. (1989). Computer-assisted visual-perceptual training. Journal of Head
Trauma Rehabilitation, 4(2), 75-77.

Lynch, W. (1989). Ethics in computer-assisted cognitive retraining. Journal of Head
Trauma Rehabilitation, 4(1), 91-93.

Lynch, W. J. (1990) Adaptive devices for microcomputers. . .part 3. Journal of Head
Trauma Rehabilitation, 5(1), 96-99.

Lynch, W. J. (1990) Cognitive prostheses for the brain impaired. Journal of Head
Trauma Rehabilitation, 5(3), 78-80.

Lynch, W. J. (1990) Computer access for the disabled: Entering the new decade. Journal
of Head Trauma Rehabilitation, 5(2), 87-89.

Lynch, W. J. (1992) Ecological validity of cognitive rehabilitation software. Journal of
Head Trauma Rehabilitation, 7(3), 36—45.

Lynch, W. J. (1994) Hardware update: The eyegaze computer system. Journal of Head
Trauma Rehabilitation, 9(4), 77-80.

Lynch, W. J. (1989) A language master for the 1990’s. Journal of Head Trauma
Rehabilitation, 4(4), 88-90.

Lynch, W. J. (1991) The Macintosh as a tool in rehabilitation. Journal of Head Trauma
Rehabilitation, 6(4), 64-66.\

Lynch, W. J. (1989) Microcomputers in cognitive rehabilitation: New directions. Journal
of Head Trauma Rehabilitation, 4(3), 92-94.

Lynch, W. J. (1990) Selecting a computer for rehabilitation. Journal of Head Trauma
Rehabilitation, 5(4), 101-103.

Lynch, W. J. (1992) Selecting patients and software for computer-assisted cognitive
retraining: Key patient variables to consider. . .part 2. Journal of Head Trauma
Rehabilitation, 7(2), 106-108.

Lynch, W. J. (1992) Selecting patients and software for computer-assisted cognitive
retraining: Screening candidates for treatment... part 1. Journal of Head Trauma

214

Rehabilitation, 7(1), 92-95.

Lynch, W. J. (1994) Software update. . .Cognitive rehabilitation (CR) software. Journal of
Head Trauma Rehabilitation, 9(2), 105-108.

Lynch, W. J. (1998) Software update 1998: Commercial programs useful in cognitive
retraining. Journal of Head Trauma Rehabilitation, 13(5), 91-94.

Lynch, W. J. (1992) Suggestions for the next generation of cognitive rehabilitation
software: Memory software. . .part 1. Journal of Head Trauma Rehabilitation,
7(4), 109-111.

Lynch, W. J. (1995) Technology. Microcomputer-assisted neuropsychological test
analysis. Journal of Head Trauma Rehabilitation, 10(2), 97-100.

Lynch, W. J. (1996) Tests, measurement, and technology. Computer-administered
cognitive assessment update. . .The Colorado neuropsychological tests. Journal of
Head Trauma Rehabilitation, 11(2), 99-101.

Lynch, W. J. (1993) Update on a computer-based language prosthesis for aphasia
therapy. Journal of Head Trauma Rehabilitation, 8(3), 107-109.

Lynch, W. J. (1995) You must remember this: Assistive devices for memory
impairment. . .NeuroPage. . .Voice it personal note recorder. . .Voice organizer.
Journal of Head Trauma Rehabilitation, 10(1), 94-97.

Lyons, J. L., & Morse, A. R. (1988). A therapeutic work program for head-injured adults.
American Journal of Occupational Therapy, 42(6), 364-370.

Mann, W. C., & Dittmar, S. S. (1992). Consumer advocacy and professional education:
Traumatic brain injury. Journal of Cognitive Rehabilitation, 10(6), 8-11.

Mann, W. C., & Svorai, S. B. (1994). COMPETE: A model for vocational evaluation,
training, employment, and community for integration for persons with cognitive
impairments. American Journal of Occupational Therapy, 48(5), 446-451.

Martin, R. (1988). Legal challenges in educating traumatic brain injured students.
Journal of Learning Disabilities, 21(8), 471-485.

Mateer, C. A., Kerns, D. A., & Eso, K. L. (1996). Management of attention and memory
disorders following traumatic brain injury. Journal of Learning Disabilities,
29(6), 618-632.

Mateer, C. A., & Mapou, R. L. (1996). Understanding, evaluating, and managing
attention disorders following traumatic brain injury. Journal of Head Trauma

215

Rehabilitation, 1 1(2), 1-16.

McDowell, S. K. (1996). Update on pharmacology. A role for dopamine in executive
function deﬁcits. Journal of Head Trauma Rehabilitation, 11(6), 89-92.

Melamed, S., Groswasser, Z., & Stern, M. J. (1992). Acceptance of disability, work
involvement and subjective rehabilitation status of traumatic brain-injured (TBI)
patients. Brain Injury, 6(3), 233-243.

Miller, L. (1992). Back to the future: Legal, vocational, and quality-of-life issues in the
long-term adjustment of the brain-injured patient. Journal of Cognitive
Rehabilitation, 10(5), 14-20.

Miller, L. (1992). Cognitive rehabilitation, cognitive therapy, and cognitive style: Toward
an integrative model of personality and psychotherapy. Journal of Cognitive
Rehabilitation, 10(1), 18-29.

Millis, S. R. (1995). Factor structure of the California Verbal Leaming Test in moderate
and sever closed-head injury. Perception and Motor Skills, 80(1), 219-224.

Moore, A. D., & Stambrook, M. (1995). Cognitive moderators of outcome following
traumatic brain injury: A conception al model and implications for rehabilitation.
Brain Injury, 9(2), 109-130.

Morse, P. A., & Morse A. R. (1988). Functional living skills: Promoting the interaction

between neuropsychology and occupational therapy. Journal of Head Trauma
Rehabilitation, 3(1), 33-44.

O’Leary, S. (1991). Computer access considerations for patients with traumatic brain
injury. Journal of Head Trauma Rehabilitation, 6(3), 89—91.

O’Neill, J ., I-Iibbard, M., Brown, M., Jaffe, M., Slivinski, M., Vandergroot, D., et al.
(1998). The effect of employment on quality of life and community integration
after traumatic brain injury. Journal of Head Trauma Rehabilitation, 13(4), 68-79.

Papworth, M. (1989). The behavioural treatment of nocturnal enuresis in a severely
brain-damaged client. Journal of Behavior Therapy and Experimental Psychiatry,
20(3), 265-268.

Parente, R., & Anderson Parente J. K. (1989). Retraining memory: Theory and
application. Journal of Head Trauma Rehabilitation, 4(3), 55-65.

Parente, R., Anderson Parente J. K., & Shaw, B. (1989). Retraining the mind’s eye.
Journal of Head Trauma Rehabilitation, 4(2), 53-62.

Parente R., & Herrmann, D. J. (1996). Retraining cognition: Techniques and

216

applications. Gaithersburg, MD: Aspen Publishers.

Parente, R., Twum, M., & Zoltan, B. (1994). Transfer and generalization of cognitive
skill after traumatic brain injury. Neurorehabilitation, 4(1), 25-35.

Parker, R. S. (1994). Neurobehavioral outcome of children’s mild traumatic brain injury.
Seminar in Neurology, 14(1), 67-73.

Penn, C., & Cleary, J. (1988). Compensatory strategies in the language of closed head
injured patients. Brain Injury, 2(1), 3-17.

Pepin, M., Loranger, M., & Benoit, G. (1995). Efﬁciency of cognitive training: Review
and prospects. Journal of Cognitive Rehabilitation, 13(4), 8-14.

Persel, C. S., & Persel, C. H. (1995). The use of applied behavior analysis in traumatic
brain injury rehabilitation. In M. J. Ashley & D. K. Krych (Eds.), Traumatic brain
injury rehabilitation (pp. 231-273). Boca Raton, FL: CRC Press.

Possl, J ., & Yves Von Cramon, D. (1996). Clients’ view of neuropsychological
rehabilitation. Brain Injury, 10(2), 125-132.

Powell, B. D., & Holmes, C. B. (1995). Prevalence of head injury among four-year
college students: A replication and combined results. Perception and Motor Skills,
81(1), 227-230.

Prickel, D., & McLean, B. (1989). Vocational rehabilitation of the head injured person in
the rural setting. Cognitive Rehabilitation, 7(6), 22-26.

Prigatano, G. P. (1987). Recovery and cognitive retraining after craniocerebral trauma.
Journal of Learning Disabilities, 20(10), 603-613.

Prigatano, G. P. (1997). Learning from our successes and failures: Reﬂections and
comments on “Cognitive rehabilitation: How it is and how it might be. “Journal
of International Neuropsychology and Sociology, 3(5), 497-499.

Rao, N., & Kilgore, K. M. (1992). Predicting return to work in traumatic brain injury
using assessment scales. Archives in Physical and Medical Rehabilitation, 73(10),
91 1-916.

Raymer, A. M., Gonzales Rothi L. J., & Greenwald, M. L. (1995). The role of cognitive
models in language rehabilitation. Neurorehabilitation, 5(2), 183-193.

Richards, L. (1995). Providing instruction in independent living and vocational

rehabilitation for individuals with head injuries within an entry-level occupational
therapy curriculum. Occupational Therapy and Health Care, 9(1), 57-70.

217

Ried, 8., Strong G., Wright, L., Wood, A., Goldman, A., & Bogen, D. (1995).
Computers, assistive devices, and augmentative communication aids: Technology
for social inclusion. Journal of Head Trauma Rehabilitation, 10(5), 80-90.

Rizzo, A. A. Buckwalter, J. G., & Neumann, E. (1997). Virtual reality and cognitive
rehabilitation: A brief review of the future. Journal of Head Trauma
Rehabilitation, 12(6), 1-15.

Rose, F. D., Al-Khamees, K. Davey, M. J ., & Attree, E. A. (1993). Environmental
enrichment following brain damage: An aid to recovery or compensation?
Behavior Brain Research, 56(1), 93-100.

Ruff, R. M., Baser, C. A., Johnston, J. W., Marshall, L. F., Klauber, S. K., Klauber, M.
R., et a1. (1989). Neuropsychological rehabilitation: An experimental study with
head-injured patients. Journal of Head Trauma Rehabilitation, 4(3), 20-36.

Ruff, R., Mahaffey, R., Engel, J ., Farrow, C., Cox, D., & Karzmark, P. (1994). Efﬁcacy
study of THINKable in the attention and memory retraining of traumatically
head-injured patients. Brain Injury, 8(1), 3-14.

Sample, L. L., & Rowntree, A. J. (1995). Employment intervention strategies for
individuals with brain injury. Occupational Therapy and Health Care, 9(1), 45-
56.

Sander, A. M., Kreutzer, J. S., & Hernandez, C. C. (1987). Neurobehavioral functioning,
substance abuse, and employment after brain injury: Implications for vocational
rehabilitation. Journal of Head Trauma Rehabilitation, 12(5), 2841.

Savage, R. C. (1987). Educational issues for the head-injured adolescent and young adult.
Journal of Head Trauma Rehabilitation, 2(1), 1-10.

Savage, R. C. (1997). Integrating rehabilitation and education services for school-age
children with brain injuries. Journal of Head Trauma Rehabilitation, 12(2), 11-
20.

Sbordone, R. J. (1988). Assessment and treatment of cognitive-communicative
impairments in the closed-head-injury patient: A neurobehavioral-systems
approach. Journal of Head Trauma Rehabilitation, 3(2), 55—62.

Schwab, K., Grafman, J ., Salazar, A. M., & Kraft, J. (1993). Residual impairments and
work status 15 years after penetrating head injury: Report from the Vietnam head
injury study. Neurology, 43(1), 95-103.

Seaman, B., Roberts, R, Gilewski, M. & Nagai, J. (1993). Clinic to the real world:

Community reintegration of head injured patients. Journal of Cognitive
Rehabilitation, 11(2), 6-17.

218

Shaw, T. G., & Groom, K. N. (1996). Functional treatment recommendations for patients

with right hemisphere, nonverbal deﬁcits. Journal of Cognitive Rehabilitation,
14(6), 6-11.

Sherer, M., Bergloff, P., Levin, B, High, W. M., Oden, K. E., & Nick, T. G. (1998).
Impaired awareness and employment outcome after traumatic brain injury.
Journal of Head Trauma Rehabilitation, 13(5), 52-61.

Skord, K. G., & Miranti, S. V. (1994). Towards a more integrated approach to job

placement and retention for persons with traumatic brain injury and premorbid
disadvantages. Brain Injury, 8(4), 383-392.

Slade, C. (1985). The role of home therapy in cognitive rehabilitation: A team approach.
Cognitive Rehabilitation, 3(1), 10-13.

Sohlberg, M. M., & Mateer C. A. (1992a). Introduction to cognitive rehabilitation:
Theory and practice. New York, NY: Guilford Press.

Sohlberg, M. M., Mateer, C. A., & Stuss, D. T. (1993). Contemporary approaches to the
management of executive control dysfunction. Journal of Head Trauma
Rehabilitation, 8(1), 45-58.

Sohlberg, M. M., & Raskin, S. A. (1996). Principles of generalization applied to attention
and memory interventions. Journal of Head Trauma Rehabilitation, 11(2), 65-78.

Spring, B. J ., & Ravdin, L. (1992). Cognitive remediation in schizophrenia: Should we
attempt it? Schizophrenia Bulletin, 18(1), 15-20.

Stapleton, M., Parente, R., & Bennett, P. (1989). Job coaching traumatically brain injured
individuals: Lessons learned. Cognitive Rehabilitation, 7(4), 18-21.

Stern, J. M., & Stern, B. (1989). Visual imagery as a cognitive means of compensation
for brain injury. Brain Injury, 3(4), 413-419.

Strauss, D. L., & Schaffer, V. L. (1995). A transformation to real-life rehabilitation.
Continued Care, 14(6), 31 -35.

Sturm, W., Willmes, K., Orgass, B., & Hartje, W. (1997). Do specific attention deﬁcits
need specific training? Neuropsychological Rehabilitation, 7(2), 81-103.

Suzman, K. B., Morris, R. D., Morris, M. K., & Milan, M. A. (1997). Cognitive-
behavioral remediation of problem solving deﬁcits in children with acquired brain

injury. Journal of Behavior Therapy and Experimental Psychiatry, 28(3), 203-
212.

219

Tate, R. L. (1997). Beyond one-bun, two-shoe: Recent advances in the psychological
rehabilitation of memory disorders after acquired brain injury. Brain Injury,
11(12), 907-918.

Thomas, D. F., & Menz, F. E. (1990). Development, implementation, and validation of
supported employment model(s) for traumatically brain injured persons. Head
Injury Re-Entry Project (Project HIRe). Washington, DC: National Institute on
Disability and Rehabilitation Research.

Thomas, D. F., Menz, F. E., & McAlees, C. C. (1993). Community-based employment
following traumatic brain injury. Washington, DC: National Institute on
Disability and Rehabilitation Research.

Thomas, S. N ., Johnson, P., Schuller, R., & Jutai, J. (1994). Evaluation of a computer-
based program for remediation of cognitive communication skills. Journal of
Head Trauma Rehabilitation, 9(4), 25-37.

Toglia, J. P. (1991). Generalization of treatment: A multicontext approach to cognitive
perceptual impairment in adults with brain injury. American Journal of
Occupational Therapy, 45(6), 505-516.

Treadwell, K., & Page, T. J. (1996). Functional analysis: Identifying the environmental
determinants of severe behavior disorders. Journal of Head Trauma
Rehabilitation, 11(1), 62-74.

Trexler, L. E., & Zappala, G. (1988). Re-examining the determinants of recovery and

rehabilitation of memory defects following traumatic brain injury. Brain Injury,
2(3), 187-203.

Uomoto, J. M. (1992). Neuropsychological assessment and cognitive rehabilitation after
brain injury. Traumatic Brain Injury, 3(2), 291-317.

Veach, R. (1993). Utilization of community resources in a community-based
rehabilitation program for mild to mild-moderate brain-injured survivors. Journal
of Cognitive Rehabilitation, 11(2), 18-20.

Veach, R., & Taylor, M. (1989). Vocational placement of minor head injured survivors.
Cognitive Rehabilitation, 7(4), 14-16.

Venzie, D. R., Felicetti, T., & Cerra Tyl D. (1996). Planning considerations for
community integrative brain injury programs. Journal of Head Trauma

Rehabilitation, 11(6), 51-64.

Volpe, B. T., & McDowell, F. H. (1990). The efﬁcacy of cognitive rehabilitation in
patients with traumatic brain injury. Archives of Neurology, 47(2), 220-222.

220

Von Cramon, D., Matthes Von Cramon, G., & Mai, N. (1991). Problem-solving deﬁcits
in brain-injured patients: A therapeutic approach. Neuropsychological
Rehabilitation, 1(1), 45-64.

Von Cramon, D. Y., & Matthes Von Cramon, G. (1994). Back to work with a chronic
dysexecutive syndrome? A case report. Neuropsychology and Rehabilitation,
4(4), 399-417.

Von Cramon, D. Y., & Matthes Von Cramon, G. (1992). Reﬂections on the treatment of
brain-injured patients suffering from problem-solving disorders.
Neuropsychological Rehabilitation, 2(3), 207-229.

Voorhees, S. L. (1985). Cognitive rehabilitation: An important aspect of the rehabilitation
approach. Cognitive Rehabilitation, 3(4), 4-7.

Wall, J. R., Niemczura, J. G., & Rosenthal, M. (1998). Community-based training and
employment: An effective program for persons with traumatic brain injury.
Neurorehabilitation, 10(1), 39-49.

Walsh, C. (1995). Subacute care. Managing a head injury program. Provider, 21(6), 38.

Walsh, W. (1984). The challenge of treating post head trauma patients. Journal of the
American Health Care Association, 10(1), 64-69.

Webb, D. (1991). Increasing carryover and independent use of compensatory strategies in
brain injured patients. Cognitive Rehabilitation, 9(3), 28-35.

Weber, A. M. (1990). A practical clinical approach to understanding and treating
attention problems. Journal of Head Trauma Rehabilitation, 5(1), 73-85.

Wehman, P., Kregel, J, Sherron, P., Nguyen, S., Kreutzer, J ., Fry, R., et al. (1993).
Critical factors associated with the successful supported employment placement
of patients with sever traumatic brain injury. Brain Injury, 7(1), 31-44.

Wehman, P., Kregel, J ., West, M., & Cifu, D. (1994). Return to work for patients with
traumatic brain injury. Analysis of costs. American Journal of Physical and
Medical Rehabilitation, 73(4), 280-282.

Wehman, P., Kreutzer, J ., West, M., Sherron, P., Diambra, J ., Fry, R. et al. (1989).
Employment outcomes of persons following traumatic brain injury: Pre-injury,
post-injury, and supported employment. Brain Injury, 3(4), 397-412.

Wehman, P., Kreutzer, J ., Wood, W., & Morton, M. V.(1988). Supported work model for
persons with traumatic brain injury: Toward job placement and retention [Special

issue]. Traumatic brain injury. Rehabilitation Counseling Bulletin, 31(4), 298-
312.

221

Wehman, P., Sherron, P., Kregel, J ., Kreutzer, J ., Tran, S., & Cifu, D. (1993). Return to
work for persons following severe traumatic brain injury. Supported employment

outcomes after ﬁve years. American Journal of Physical and Medical
Rehabilitation, 72(6), 355-363.

Wehman, P. H., Kreutzer, J. S., West, M. D., Sherron, P. D., Zasler, N. D., Groah, C. H.,
et al. (1990). Return to work for persons with traumatic brain injury: A supported

employment approach. Archives of Physical and Medical Rehabilitation, 71(13),
1047- 1052.

Wehman, P., West, M., Fry, R., Sherron, P., Groah, C., Kreutzer, J ., et al. (1989). Effect
of supported employment on the vocational outcomes of persons with traumatic
brain injury. Journal of Applied Behaviour Analysis, 22(4), 395-405.

Wehman, P. H., West, M. D., Kregel, J ., Sherron, P., & Kreutzer, J. S. (1995). Return to
work for persons with severe traumatic brain injury: A data-based approach to
program development. Journal of Head Trauma Rehabilitation, 10(1), 27-39.

Wesolowski, M. D., & Zencius, A. H. (1994). A practical guide to head injury
rehabilitation: A focus on postacute residential treatment. New York, NY:
Plenum Press.

West, M., Wehman, P., Kregel, J ., Kreutzer, J ., Sherron, P., & Zasler, N. (1991). Costs of
operating a supported work program for traumatically brain-injured individuals.
Archives of Physical and Medical Rehabilitation, 72(2), 127-131.

West, M. D. (1995). Aspects of the workplace and return to work for persons with brain
injury in supported employment. Brain Injury, 9(3), 301-313.

White, S. M., Seckinger, S. Doyle, M., & Strauss, D. L. (1997). Compensatory strategies
for people with traumatic brain injury. Neurorehabilitation, 9(3), 205-212.

Whyte, J. (1986). Outcome evaluation in the remediation of attention and memory
deﬁcits. Journal of Head Trauma Rehabilitation, 1(3), 64-71.

Wilde, M. C., Boake, C., & Sherer, M. (1995). Do recognition-free recall discrepancies
detect retrieval deﬁcits in closed-head injury? An exploratory analysis with the
California verbal learning test. Journal of Clinical and Experimental
Neuropsychology, 17(6), 849-855.

Willer, B., & Corrigan, J. D. (1994). Whatever it takes: A model for community-based
services. Brain Injury, 8(7), 647-659.

Willer, B., Rosenthal, M., Kreutzer J. S., Gordon, W. A., & Rempel, R. (1993).
Assessment of community integration following rehabilitation for traumatic brain

222

injury. Journal of Head Trauma Rehabilitation, 8(2), 75-87.

Wilson, B. (1992). Recovery and compensatory strategies in head injured memory
impaired people several years after insult. Journal of Neurological Neurosurgery
and Psychiatry, 55(3), 177-180.

Wilson, B. A. (1997). Cognitive rehabilitation: How it is and how it might be. Journal of
Neuropsychology and Sociology, 3(5), 487-496.

Wilson, B. A. (1991). Long-term prognosis of patients with severe memory disorders.
Neuropsychological Rehabilitation, 1(2), 117-134.

Wilson, B. A. (1998). Recovery of cognitive functions following non-progressive brain
injury. Current Opinions in Neurobiology, 8(2), 281-287.

Wilson, B. A. (1994). Syndromes of acquired dyslexia and patterns of recovery: A 6 to
10 year follow-up study of seven brain-injured people. Journal of Clinical
Experimental Neuropsychology, 16(3), 354-371.

Wilson, B. A., Baddeley, A., Evans, J ., & Shiel, A. (1994). Errorless learning in the
rehabilitation of memory impaired people. Neuropsychological Rehabilitation,
4(3), 307-326.

Wilson, B. A., & Evans, J. J. (1996). Error-free learning in the rehabilitation of people
with memory impairments. Journal of Head Trauma Rehabilitation, 11(2), 54-64.

Wood, R. L. (1987). Brain injury rehabilitation: A neurobehavioural approach. London:
Croom Helm.

Ylvisaker, M., Feeney, T. Maher Maxwell, N., Meserve, N., Geary, P. J ., & DeLorenzo,
J. P. (1995). School reentry following severe traumatic brain injury: Guidelines
for educational planning. Journal of Head Trauma Rehabilitation, 10(6), 25-41.

Ylvisaker, M., Hartwick, P., & Stevens, M. (1991). School reentry following head injury:
Managing the transition from hospital to school. Journal of Head Trauma
Rehabilitation, 6(1), 10—22.

Youngson, H. A., & Alderman, N. (1994). Fear of incontinence and its effects on a
community-based rehabilitation programme after severe brain injury: Successful
remediation of escape behavior using behavior modiﬁcation. Brain Injury, 8(1),
23-36.

Yuen, H. K., & Benzing, P. (1996). Treatment methodology. Guiding of behavior
through redirection in brain injury rehabilitation. Brain Injury, 10(3), 229-238.

Zasler, N. D. (1997). The role of medical rehabilitation in vocational reentry. Journal of

223

Head Trauma Rehabilitation, 12(5), 42-56.

Zencius, A., Wesolowski, M. D., & Burke, W. H. (1989). Comparing motivational
systems with two non-compliant head-injured adolescents. Brain Injury, 3(1), 67-
71.

Zhou, J ., Chittum, R., Johnson, K., Poppen, R., Guercio, J ., & McMorrow, M. J. (1996).

The utilization of a game format to increase knowledge of residuals among people
with acquired brain injury. Journal of Head Trauma Rehabilitation, 11(1), 51-61.

224

REFERENCES

Alderman, N. (1991). The treatment of avoidance behavior following severe brain injury
by satiation through negative practice. Brain marry, 5(1), 77-86.

Anderson, J .R. (1980). Cognitive psychology and its implications (2"(1 ed.), New York:
W.H. Freeman and Company.

Annegers, J ., Grabow, J ., Kuland, L., & Laws, E. (1980). The incidence, causes, and
secular trends of head trauma in Olmstead County, Minnesota, 1935-1974.
Neurology, 30, 912-991.

Antonak, R.F., Livneh, H., & Antonak, C. (1993). A review of research on psychosocial
adjustment to impairment in persons with traumatic brain injury. Journal of Head
Trauma Rehabilitation, 8(4), 87-100.

Babbie, E. (2001). The practice of social research (9th ed.) Belmont, CA:
Wadsworth/Thomson Learning.

Ben-Yishay, Y., Rattok, J ., Lakin, P., Piasetsky, E., Ross, B., Silver, 5., Zide, E., &
Ezrachi, O. (1985). Neuropsychological Rehabilitation: Quest for a Holistic
Approach. Seminﬁars in Neurology, 5 (3), 252-259.

Ben-Yishay, Y., Silver, 8., Piasetsky, E., & Rattok, J. (1978). Relationship between
employability and vocational outcome after intensive holistic cognitive
rehabilitation. Jouraal of Head Trauma Rehabilitation, 2 (1), 35-48

Beme, E. (1961). Transactional analysis in psychotherapy. New York: Ballantine
Books.

Blair, C.D., & Lanyon, RI. (1987). Retraining social skills and adaptive living skills in
severely head injured adults. Archives of Clinical Neuropsychology. 2, 33-43.

Bond, MR. (1975). Assessment of the psychosocial outcome after severe head injury.
Ciba Foundation Symposium, 34, (pp. 141-157).

Bond, MR. (1990). Scale and scope of the problem. In M. Rosenthal, E. Grifﬁth, & J.
Miller (Eds.), Rehabilitation of the adult and child with traumatic brain injury (PP.
3-37). Philadephia: F.A. Davis.

Brooks, N., Aughton, M.E., & Bond, MR. (1980). Cognitive sequelae in relationship to

early indices of severity of brain damage after severe blunt head injury. Journal of
Neurology, Neurosurgery, and Psychiatry, 43, 529-534.

225

Brooks, N. (1984). Cognitive Deﬁcits After Head Injury. In N. Brooks (Ed.), Closed
head injury: psychological, socia_l,_and family consequences. New York: Oxford
University Press.

Carew, T.J. (1985). Posture and Locomotion. In E. Kandel & J. Schwartz (Eds.),
Principles of neuroscience, 2nd Edition. New York: Elsevier.

Cartlidge,N.E. (1981). Head injug. London: W.B. Saunders.

Castro, G. & Mastropieri, M. A. (1986). The efficacy of early intervention programs: A
meta-analysis. Exceptional Children, 52, 417-424.

Center for Disease Control and Prevention, National Center for Injury Prevention and
Control. (1998). 1994 National hospital discharge survey. Unpublished analysis of
data.

Center for Disease Control and Prevention, National Center for Injury Prevention and
Control. (1997). Traumatic brain injury, Colorado, Missouri, Oklahoma, and Utah-
1990-1993. MMWR Morb. Mortam/ Weeﬁy, 46, 8-11.

Christensen, A. L. (1986). Applying Luria's theory to the rehabilitation process of brain
damage. In B. Uzzell & Y. Gross (Eds.), Clinical neuropsychology of intervention
(pp. 169-177). Boston: Martinus Nijhoff.

Cicerone, K.D. (1989). Psychotherapeutic interventions with traumatically brain-injured
patients. Rehabilitation Psychology, 34, 105-114.

Cooper, K.D., Tabaddor, K., Hauser, W.A. (1983). The epidemiology of head injury in
the Bronx. Neuroepidemiology, 2, 70-88.

Crane, A.A., & Joyce, B.G. (1991). Cool down: A procedure for decreasing addression in
adults with traumatic brain injury. Behrﬂoral Residential Treatment, 6(1), 65-75.

Crosson, B. (1987). Treatment of interpersonal deficits for head-trauma patients in
inpatient rehabilitation settings. The Clinical Neuropsychologist, 1, 335-352.

Crowley, J. A. & Miles, M. A. (1991). Cognitive remediation in pediatric head injury: A
case study. Journal of Pediatric Psychology, 16 (5), 611-627.

Davis, 8., & Palladono, J. (2002). Psychology (3rd edj, Upper Saddle River, New Jersey:
Prentice Hall.

Delmonico, R.L., Hanley-Peterson, P., & Englander, J. (1998). Group psychotherapy for

persons with traumatic brain injury: management of frustration and substance
abuse. Jouml of Head trauma Rehabilitation, 13, 10—22.

226

Duncan, J. (1986). Disorganization of behaviour after frontal lobe damage. Cogaitive
Neuropsychology, 3(3), 271-290.

Eysenck, H. (1984). Meta-analysis: An abuse of research integration. Journal of Special
Education, 18, 41-59.

Fisher, J .M. (1985). Cognitive and behavioral consequences of closed head injury.
Seminars in Neurology, 5(3), 197-204

Frankowski, R. (1986). Descriptive epidemiologic studies of head injury in the U.S.:
1974-1984. In L. Karger & T. Basel, Trauma treatment in practise. The head
injured patient. Advanced Psychosomtic Medicine, 16, 152-172.

Frankowski, R., Klauber, M.R., & Tabaddor, K. (1981). Head injury mortalitw A
comparison of three metropolitan counties. NINCDS report (manuscript).

Fujii, D. E. (1996). Kolb's learning styles and potential cognitive remediation of brain-
injured individuals: An exploratory factor analysis study. Professional
Psychology: Research and Practice, 27 (3), 266-271.

Gallo, P. (1978). Meta-analysis: A mixed metaphor? American Psycholggist, 33, 515—
517.

Gans, J .S. (1983). Hate in the rehabilitation setting. Archives of Physical Medicine m
Rehabilﬁrtion, 64, 176-179.

Garoutte, B., & Aird, R. (1984). Behavioral effects of head injury. Psychiatric Annuals,
14, 507-514.

Glass, G., McGaw, B., & Smith, M. (1981). Meta-analysis in socigiresearch. Beverly
Hills: Sage.

 

Grant, 1., & Alves, W. (1987). Psychiatric and psychosocial disturbances in head injury.

In H.S. Levin, J. Grafman, & H.M. Eisenberg (Eds.), Neurobehaviog recovery
from head injury, (pp. 232-261). New York: Oxford University Press.

Grimm, B.H., & Bleiberg, J. (1986). Psychological rehabilitation in traumatic brain
injury. In S.B. Filsov & T.J. Boll (Eds.), Handbook of Clinical Neuropsychology.
(pp. 495-527). New York: John Wiley and Sons.

Gualtieri, T., & Cox, DR. (1991). The delayed neurobehavioral sequelae of traumatic
brain injury. Brain Injury, 5, 219-232.

Haslam, C., Batchelor, J ., & Feamside, MR. (1994). Post-coma disturbance and post-
traumatic amnesia as nonlinear predictors of cognitive outcome following severe

227

closed head injury: Findings from the Westmead Head Injury Project. Brain
Injury, 8, 519-528.

Hedges, L. (1986). Issues in meta-analysis. Review of Research in Education, 13, 353-
398.

Huffman, K., Vemoy, M., & Vemoy, J. (2000). Psychology in action (5’h ed.), New
York: John Wiley & Sons, Inc.

 

Hurt, GD. (1991). Mild brain injury: Critical factors in vocational rehabilitation.
Journal of Rehabilitation, 57 (4), 36-40

Jennett, B., & Teasdale, G. (1981). Management of head injuries. Contemporary
Neurology Series, Vol. 20. Philadelphia: FA Davis.

Jennett, B., & Macmillan, R. (1981). Epidemiology of head injuries. British Medical
Journal, 282, 101-103.

Johnson, P., Thomas-Stonell, N., & Shein, F. (1994). Development of a computer-based
program for the remediation of cognitive-communication skills in young people
with head injuries. Journal of Cognitive Rehabilitation, July/August, 12 (4), 10-18.

Kaplan, SP. (1988). Adaptation Following Serious Brain Injury: An Assessment After
One Year. Journal of Applied Rehabilitation Counseling, 19 (3) 3-8.

Kassin, S. (2001). Psychology (3"1 Ed). Upper Saddle River, New Jersey: Prentice Hall.

Klauber, M.R., Barret-Connor, B, Marshall, L.F., & Bowers, SA. (1978). The
epidemiology of head injury: A prospective study of an entire community-San
Diego County, California, 1978. American Journal of Epidemiology, 113, 500-509.

Klove, H. & Cleeland, CS. (1972). The relationship of neuropsychological impairment to
other indices of severity of head injury. Saandinavian Journal of Rehabilitation
Medicine, 4, 155-160.

Kohut, H. (1972). Thoughts on narcissism and narcissistic rage. Psychoanalytic Study of
the Child 27, 360-400.

 

Kreutzer, J .S., Leininger, B.S., Sherron, P.D., & Groah, CH. (1990). Managing
psychosocial dysfunction. In P. Wehman & J .S. Kreutzer (Eds.), Vocational
re_habilitaftion for persons with traumatic brain injury (pp. 35-69). Rockville, MD:
Aspen Publication.

Kwentus, J ., Hart, R., Peck, E., & Kornstein, S. (1985). Psychiatric complications of
closed head trauma. Psychosomatic, 26, 8-17.

228

Lashley, K. S. (1938). Factors limiting recovery after central nervous lesions. The
Journal of Nervous and Mental Diseases, 88, 733-755.

Lezak, MD. (1987). Relationships between personality disorders, social disturbances,
and physical disability following traumatic brain injury. Journal of Head Trauma
Reiabilitation, 2(1), 57-69.

Lishman,W.A. (1978). Organic psychiatry. Oxford: Blackwell Scientific Publications.

Lishman, W.A. (1973). The psychiatric sequelae of head injury: A review. Psychological
Medicine, 3, 304-318.

Livneh, H., & Antonak, RF. (1990). Reactions to disability: An empirical investigation

of their nature and structure. Journal of Applied Relgbilitation Counseling, 21(4),
13-21.

Long, DP. (1989). Issues in behavioral neurology and brain injury> In D.W.Ellis & A.
Christensen (Eds.), Neuropsychological treatment after brain injury (pp. 39-90).
Boston: Kluwer Academic Publishers.

Luria, A. R. (1983). Recovery of brain function after brain injury. New York: Macmillan
Co.

McAllister, T.W. (1997). Evaluation of brain injury related behavioral disturbances in
community mental health centers. Community Mental Health Journal, 33, 341-351.

McClelland, R.J. (1988). Psychosocial sequelae of head injury: Anatomy of a
relationship. British Jorﬂal of Psychiatg, 153, 141-146.

McMordie, W., Barker, 8., & Paolo, T. (1990). Return to work after head injury. Brain
Injury, 4, 57-69.

Morse, P.A., & Montgomery, CE. (1992). Neuropsychological evaluation of traumatic
brain injury. In White R.F. (Ed.), Clinical syndromes in adult neuropsychology: The
pgctitioner’s handboak (pp. 85-176). New York: Elsevier Science Publishers.

Myers, D.G. (1999). Exploring Psychology (4’11 ed.), New York: Worth Publishers.
National Center for Health Statistics. (1984). Multiple causes of death in the United

States: Monthly vital statistics report, vol. 32. (Report No. 84-1120). Hyattsville,
Maryland: Public Health Service.

National Center for Health Statistics (1994). Multiple causes of death in the United

States: Public data for years 1980-1994. Hyattsville, Maryland: Public Health
Service.

229

National Head Injury Foundation. (1984). Unpublished Document. National Head
Injury Foundation, Inc., Framingham, MA.

Nelson, A.J. (1983). Motor Assessment. In M. Rosenthal (Ed.), Rehabilitation of the
Ed Injured Adult. Philadelphia: F.A. Davis.

Oddy, M., Coughlan, T., Tyerrnan, A., & Jenkins, D. (1985). Social Adjustment after
Closed Head Injury: A Further Follow-up Seven Years after Injury. Journal of
Neurology, Neurosurgery, and Psychiatry, 43, 798-802.

Pepping, M., & Roueche, J .R. (1991). Psychosocial consequences of signiﬁcant brain
injury. In D.E. Tupper & K.D. Cicerone (Eds.), The neuropsychology of everyday
life: Issues in developmermd rehabilitation (pp. 215-256). Boston: Kluwer
Academic Publishers.

Plum, F., & Levy, DE. (1978). Predicting Prognosis in Coma: Can One Improve
Medical Decisions? American Jouraal of Medicine, 65, 224-226.

Prigatano, G. P. (1987a). Neuropsychological Deﬁcits, Personality Variables, and
Outcome. In M. Ylvisaker & E. Gobble (Eds.), Community re-entry for head
injured adults. Boston: College-Hill.

Prigatano, G. (1987b). Recovery and cognitive retraining after craniocerebral trauma.
Journal of Learning Disabilities, 20 (10) 603-613.

Prigatano, G.P. (1987c). Psychiatric aspects of head injury: Problem areas and suggested
guidelines for research. In H.S. Levin, J. Grafman, & H.M. Eisenberg (Eds.),
Neurobehavioral recovery from head injury (pp. 215-231). New York: Oxford
University Press.

Prigatano, G.P., Bruna, O., Mataro, M., Munoz, J .M., Fernandez, S., & Junque, C.
(1998). Initial disturbances of consciousness and resultant impaired awareness in
Spanish patients with traumatic brain injury. In G.P. Prigatano, D.J., Fordyce, H.K.
Zeiner, J .R. Roueche, M. Pepping, & B.C. Woods (Eds.), Neuropsychological
rehabilitation after brain injury. Baltimore: The John Hopkins University Press.

Rimel, R.W., & Jane, J .A. (1983). Characteristics of Head-Injured Patient. In M.
Rosenthal, E. Grifﬁth, M. Bond, & J. Miller (Eds.), Rehabilitation of the head
injured adult. Philadelphia: F.A. Davis.

Rosenthal, M. (1983). Behavioral Sequelae. In M. Rosenthal (Ed.), Rehabilitation of
the Head Injured Adult. Philadelphia: F.A. Davis.

Routh, D. K. (1987). Cognitive rehabilitation for children with head injury, learning
disability, and mental retardation. Cognitive Rehabilitation, November/December,
16-21.

230

Sherzer, B. P. (1986). Rehabilitation Following Severe Head Trauma: Results of a

Three-Year Program. Archives of msical Medicine and Rehabilitation, 67,
366-374.

Silver, J .M., Yudofsky, S.C., & Hales, RE. (1991). Depression in traumatic brain injury.
Neurgrsychiatry, Neuropsychology, and Behavioral Neurolggy, 4, 12-23.

Shores, EA. (1989). Comparison of the Westmead PTA scale and the Glasgow Coma
Scale as predictors of neuropsychological outcome following extremely severe
blunt head injury. Journal of Neurology. Neurosurgeryl and Psychiatry, 52, 126-127.

Slagle, DA. (1990). Psychiatric disorders following closed head injury: An overview of
biopsychosocial factors in their etiology and management. International Journal of
Psychiatry in Medicine, 20(1), 1-35.

Springer, S.P., & Deutsch, G. (1985). Left brain right brain. New York: W.H.
Freeman.

Sunderland, A., Curry, S. H., Das, S., Enderby, P. M., Kinsey, C., Mortley, J ., &
Petheram, B. (1992). Monitoring information-processing efﬁciency after stroke or
head injury: A comparison of four computerised tests for use in single case
experiments. Neuropsycholcﬂcal Rehabilitation, 2 (2), 137-149.

Swanson, H. L. (1996). Meta-analysis, replication, social skills, and learning disabilities.
The Journal of Special Education, 30(2), 213-221.

Symond, GP. (1937). Mental disorder following head injury. Proceedings of the Royal
Society of Medicine, 30, 1081-1092.

Teasdale, G., & Jennet, B. (1974). Assessment of coma and impaired consciousness.
Lancet, 2, 81-84.

Thurman, D.J., Alverson, C., Dunn, K.A., Guerrero, J ., & Sniezek, G. (1999). Traumatic
brain injury in the United States: A public health perspective. Journal of Head
Trauma Rehabilitation, 14, 602-515.

Turner, J .M., Green, G., & Braunling-McMorrow, D. (1990). Differential Reinforcement
of low rates of responding (DRL) to reduce dysfunctional social behaviour of a

head injured man. Behavioral Residential Treatment, 5(1), 15-27.

Tyerrnan, A., & Humphrey, M. (1984). Changes in self-concept following severe head
injury. International Journal of Rehabilitation Research, 7(1), 11-23.

231

Varney, N.R., & Menefee, L. (1993). Psychosocial and executive deﬁcits following
closed head injury: Implications for orbital frontal cortex. Journal for Head Trauma
Rehabilitation, 8, 32-44.

Wehman, P., & Goodall, P. (1990). Return to work: Critical Issues in employment. In
P. Wehman & J .S. Kreutzer (Eds.), Vocational Rehabilitation for Persons with
Traumatic Brain Injury (p. 1-17). Maryland: Aspen Publishers, Inc.

Whitman, S., Coonley-Hoganson, R., & Desai, ET. (1984). Comparative head trauma
experience in two socio-economically different Chicago-area communities: A
population study. American Journal of Epidemiology, 4, 560-580.

Wolf, F. M. (1986). Meta-Analysis @rantitative Methods for Research Synthesis.
Beverly Hills, CA: SAGE Publications.

Zangwill, O. L. (1947). Psychological aspects of rehabilitation in cases of brain injury.
British Journal of Psychology, 37, 60-69.

Zencius, A.H., Wesolowski, M.D., & Burke, W.H. (1990). The use of visual cue to

reduce profanity in a brain injured adult. Behavioral Residential Treatment, 5(3),
143-147.

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