1. BrICC Brain Injury & Concussion Center
Clinician Training - Fall 2017
Communication Disorders & Sciences University of Oregon

2. Training Overview Welcome & Introductions Cognitive Domains
Learning Objectives
Initial Consultation
InfoCDS Resources
Assessment, Scores, Interpretation
Expectations & Communication
Treatment
Supervision & Timelines
Counseling, MI, GAS
Purpose & Populations

3. Introductions Please introduce yourself
What did you do over the summer?
What are you looking forward to this term?

4. Learning Objectives
Describe how cognitive domains operate in daily life and offer examples of how impairments to cognitive domains interfere with functioning.
Describe the components of an initial cognitive consultation.
Describe how to interpret data across multiple sources to make treatment recommendations.
Describe the ingredients of selecting the right treatment for a client and offer specific examples of how client variables influence that decision.
Describe and demonstrate how to identify client-centered goals and desired outcomes and how to use goal-attainment scaling.
Identify the difference between session data and impact data and give examples of each.

5. infoCDS Resources
ALEX

6. Resources on InfoCDS
Procedures and expectations checklists at BrICC > Student Preparation
Supervisor expectations
BrICC Documentation Checklist
BrICC Report Writing – what works and what doesn’t
Rounds and consult checklists
We aim to be completely transparent and explicit with our instructions
Please ask for clarification if anything is unclear
We won’t be able to go over all the procedures and expectations in this brief training, so you’re expected to look at the checklists, follow them, and communicate with us if anything is unclear. Go ahead locate those documents and download them to store in a folder where you can easily access them later.

7. Other Resources on InfoCDS
“Assessment” page
Psychometric conversion table
“Treatment Approaches and Intervention Materials” page
Intervention Selection Table

8. Expectations Complete Initial Consultations Plan & Implement Treatment
Prepare for and participate in BrICC Rounds
Complete Rounds Portfolio
Complete SOAPs and ITPs
Complete focused self-reflections
Reflect on supervisor changes to your documents

9. Communication Be in touch about your needs
Tell us what helps you learn
Propose plans and seek feedback
Respond to s promptly
Notify of schedule changes, cancellations
Copy supervisor in all case-related communications

10. Supervision Primarily group supervision (rounds/training sessions)
Individual support through communications
If there are complex client needs or complex personal issues, you may us to schedule an individual meeting
Midterm IPPE (performance evaluation) meetings – week 6
Download and refer to individual supervisor guidelines

11. Documentation Timelines
Lesson plans due 24 hours before the session starts
SOAPs and self-reflections due 24 hours after the session ends
Initial draft of Assessment Report due within a week of the consult
Initial draft of the ITP due: Monday October 16th (by midnight)
Final ITPs due Monday November 20th (by midnight)

12. BrICC Purpose
Complete initial consultation to assess acquired cognitive impairments and identify client desired outcomes
Identify nature of cognitive impairments and impact on activities and participation
Provide cognitive rehabilitation and/or counseling for individuals experiencing impact on function
Facilitate attainment of desired outcomes in desired contexts or settings - getting back to valued roles/activities

13. Populations Acquired brain injury (ABI) - mild, mod, severe
Acquired cognitive impairments
Traumatic brain injury (TBI)
Concussion
Persistent symptoms, multiple concussions
Neurogenic populations with cognitive impairments
e.g., Parkinson’s, Huntington’s, stroke, primary progressive aphasia

14. Population Characteristics
Cognitive symptoms
--Impaired attention, memory, executive function
Somatic symptoms
--Headache, light sensitivity, nausea, dizziness
Psychosocial changes
--Decreased social engagement, irritability, flat affect

15. Feeling ready to get busy? Kinda like this....
ALEX

16. HEIDI

17. Cognitive Domains
HEIDI

18. Cognitive Domains Attention Memory Executive Function
Social communication (e.g. pragmatics, theory of mind, social problem solving)

19. Cognitive Domains – Clinical Decision Making & Documentation
Clinical decisions should be based on an understanding of WHAT underlying cognitive domain you are treating, as well as WHY and HOW you are treating it
Confusing domains can impact clinical decision making and client progress
When explaining assessment and treatment options to clients, use simple language to talk about “attention,” “executive functions,” and different types of memory – examples help
With a clear understanding of cognitive domains, you will write clearer goals, ITPs, and assessment reports with fewer supervisor edits

20. Attention Focused Attention – put your attention on something
Sustained Attention – keep your attention on something
Working Memory – hold info in mind to use it in some way
Suppression – ignore, suppress, inhibit what you don’t need to attend to
Alternating Attention – switch attention between tasks or different info
Selective Attention – deliberately pick out info to attend to from other info
(Sohlberg & Mateer, 2010)

21. Types of Memory
Short-term – hold info in mind to manipulate it (WM in some models)
Long-term – store of knowledge/memories - retrieve, pull into STM for use
Declarative – knowledge of info or events
---Semantic – knowledge anyone could find on Wikipedia
....“What’s the capital of Iceland?”..... “How many states in the US?”
---Episodic – knowledge particular to your experiences
....”What happened at the meeting?” ...”Who visited?”
Prospective – remember to do something later (e.g., stop by store)
Nondeclarative/implicit – skills, habits, implicit learning
---Procedural (e.g. ride bike, tie shoes)

22. Types of Memory vs. Memory Tasks
RBANS includes immediate and delayed memory tasks
Immediate memory task – recall immediately after
Delayed memory task – recall after a delay
Immediate & delayed TASKS are not types of memory
As SLPs, we want to help clients with memory tasks in real life – not just get better scores – so we focus treatment on compensatory strategies
Interpret test performance relative to routine function – connect to interview data

23. Addressing Memory in Treatment
Insufficient evidence for impairment-based approaches (e.g., drills)
Avoid stating or writing that you aim to “improve” memory
Evidence suggests compensatory memory strategies can be effective
Compensatory strategies:
External aids
Internal memory strategies
Environmental modifications
Communication partner training
Working memory can be targeted as a component of attention

24. Executive Functions Initiation & drive - starting behavior
Response inhibition - stopping behavior
Task persistence - maintaining behavior
Organization - sequencing & timing behavior
Generative thinking - creativity, fluency, problem solving skills
Awareness - self evaluation & insight
(Sohlberg & Mateer, 2005)

25. Impact on Function, Activity and Participation
Symptoms can differentially impact routine function to varying degrees
--School attendance and performance
--Work attendance and performance
--Social involvement and social networks

26. Contributing Factors
Many factors can contribute to cognitive difficulties
mTBI
headaches, chronic pain
anxiety, depression, PTSD
sleep difficulties
substance use disorders
life stressors
Recruit resilience
Focus on facilitating the recovery process
Create a context for working through difficulties and moving forward
(Clinician's Guide to Cognitive Rehabilitation in mTBI, 2016)

27. Initial Consultations
ALEX

28. Consult Templates in RDS
CDS > CDS Templates > BrICC > BrICC eval templates shortcut
Adult and Adolescent ABI cases
Adult neurodegenerative (use for Parkinson’s, Alzheimer’s, dementia, etc.)
Use the Consult Checklist to prep for consults
Use complete sentences, narrative format

29. Principles of Assessment
Client-centered
Identify functional impairments and impact
Use counseling skills (including but not limited to motivational interviewing)
Collaborative goal-setting (use GAS/eGAS)
Follow checklists/guides on infoCDS under Student Preparation and Planning Materials >Consults

30. Consultation Overview
Clinical interview (45 min)
Learn about presenting concerns, impact of sx on routine
Motivational interviewing + eGAS
Present possible treatment options to address concerns
Standardized battery/other protocols (1 hr, 15 min)
RBANS – every consult
TEA/TEA-Ch, BRIEF, D-KEFS, LASSI – as needed based on file review
PCSS, HIT – somatic sx after concussion

31. Template = A guide, not a rigid protocol
Adapt format, structure and components of templates as needed in consultation with supervisor

32. Standardized Batteries
RBANS
Refer to presentation titled ‘RBANS Update: Repeatable Battery for the Assessment of Neuropsychological Status’ by Anne-Marie Kimbell, PhD
TEA/ TEA-Ch – Versions A, B & C – begin with version A – administer full test
Course content – Management of Acquired Cognitive Disorders
BRIEF
LASSI
D-KEFS
Refer to training by Gloria Maccow, PhD

33. Types of Assessment Data
File review data
Clinical interview data
Behavioral observations
Standardized test scores
Questionnaire data

34. Types of Scores Standard scores (M = 100, sd = 15)
Comparing performance to a standardized sample
Scaled scores (M = 10, sd = 3)
Subtests often yield scaled scores
T scores (M = 50, sd = 10)
Determining clinical significance of a score
Z scores (M = 0, sd = 1)
Determining distance of given score from mean
(X – M)/s = Z (scores’s distance from the mean)

35. Scoring – General Helpful Principles
Know the different types of scores possible
Read the scoring procedures in the manual
Read what the manual says about how to interpret scores
Draw simple graphics to talk about scores

36. Scoring & Interpretation – A Handy Reference
Psychometric Conversion Table
infoCDS > BrICC > Assessment
Download and keep available for future reference in interpreting scores

37. Interpretation So much data, so little time! What does it all mean?
What hypotheses did you have at the start of the assessment?
Return to your hypotheses when interpreting data

38. Interpretation Interpretation should be based on hypothesis testing
Integrate data from multiple sources
Summarizing is useful and necessary, but insufficient
How are data consistent or inconsistent across sources (interview, testing, observation, etc.)?
For example - Does standardized testing data support interview data? Are data from the BRIEF consistent with test data and presenting concerns?

39. Treatment
HEIDI

40. Principles of Treatment
Recruit resilience
Cultivate therapeutic alliance
Acknowledge multifactorial complexities
Build a team
Focus on function
Promote realistic expectations for recovery
--Clinician's Guide to Cognitive Rehabilitation in mTBI (2016)

41. Treatment Options
Direct attention training combined with strategies (APT-3, AIM)
Functional skills training
Metacognitive strategy instruction
Training assistive technology for cognition (ATC)
External cognitive aids
Goal Management Training (GMT)
Personalized education
Environmental modifications/support

42. Treatment Selection Process
Consider
Client data - concerns, characteristics & desired outcomes
Evidence-based practice - refer to the literature
Expert knowledge - consult your supervisor
Ask
What is the rationale for selecting this approach for this client?
What barriers exist to implementing this treatment approach?
What will you measure to determine progress toward goals?
How will you take session data?
How will you measure progress toward the desired outcome?

43. Measuring Progress You will collect two types of data:
In-session data (corresponds to STOs), e.g.:
Steps performed accurately during probe using systematic instruction
Time to complete task
Accuracy
Impact or generalization data, usually measured/tracked by the client or caregiver during the week (corresponds to LTG)

44. Treatment Delivery
Determine treatment approach in collaboration with your supervisor
Refer to infoCDS, BrICC “Treatment Approaches and Intervention Materials” > “bricc-intervention-selection-table_2016_final”
Individual or group delivery options
Consultation available with Center on Healthy Relationships (formerly CFT)

45. Center on Healthy Relationships
Consultation with
Center on Healthy Relationships
Consulting therapist may address psychosocial and emotional concerns for BrICC clients
Consulting therapist may attend individual sessions per client need and clinician request
BrICC clinicians report relevant observations and consult clinical supervisor prior to seeking consultation

46. *Immediate risk of harm = emergency = Call 911*
Crisis Management
If a client expresses suicidal thoughts...
Avoid expressing shock or alarm
Calmly talk to the person
Ask if they have a plan
Let it be OK to talk about it
Offer resources (next slide)
Notify supervisor as soon as feasible
*Immediate risk of harm = emergency = Call 911*

47. Resources for Clients in Crisis
For non-UO students
Crisis Intervention Line – White Bird Clinic (24 hours / 7 days)
(541) /
Campus resources for students
After-Hours Support and Crisis Line –
UO Counseling Center

48. Plan Ahead: Your Last Session
Involve the next clinician if possible to facilitate a smooth transition
When sharing final progress with your client, take a collaborative approach
Ask them what worked/what helped
Invite their perceptions of their own progress

49. BrICC Rounds
ALEX

50. Rounds Group supervision/clinical problem solving
Every Thursday 12pm starting October 12th
You’ll receive the presentation order the day before via – changes weekly
Oral case presentation + questions
Use the checklist to prepare – focus on including all elements and being clear – conciseness and fluency will come naturally later in the term

51. Rounds - Goals and Competencies
Master professional communication and reporting skills to facilitate participation in medical rounds meetings
Further develop rational clinical decision making skills

52. Skills Developed in Rounds
Clinical Decision Making
“Clinical knowing”
Reporting
“Saying what you know”

53. Types of Reporting Case Introduction
Medical diagnosis (i.e. etiology)
Treatment diagnosis
Client/caregiver’s presenting concern
Previous history treatment
Treatment goal
Client Progress/Update Goal/Target
Approach
Measurement

54. Initial Case Introduction
Medical diagnosis (i.e. etiology)
Treatment diagnosis
Client/caregiver’s presenting concern
Previous history of treatment
Current outcome goal of therapy including
Goal
Approach
Desired Outcome

55. Rounds Portfolio
Instructions are in InfoCDS > BrICC > Student Preparation and Planning Materials
Purpose:
Focus your attention and maximize learning during rounds
Showcase your knowledge and exposure to a variety of cases when interviewing for jobs or externships
Future reference for you to look back on if you have a similar client
Update it during each time at rounds
it to your supervisor at the end of the term
Must complete to pass clinic

56. Counseling, MI, GAS
ALEX

57. Using Counseling Skills
Open-ended questions
increase collaboration, elicit “change talk”
Affirmations
Denote empathy, increase motivation
Reflections
Simple: denote empathy
Complex: increase motivation to change, self-awareness, emphasize partnership
Summary
emphasize partnership and acknowledge client’s awareness

58. Remember Your OARS
“When you head out to sea in your little boat, don’t forget your OARS.”
Open-ended questions
Affirmations
Reflections
Summary
Review notes from Cog Rehab class, MI handout, and eGAS to see examples of each

59. Electronic Goal Attainment Scaling
eGAS
Electronic Goal Attainment Scaling
Motivational interviewing: A collaborative, interviewing technique used to increase motivation, facilitate “change talk”, and elicit goals while promoting client autonomy.
Goal Attainment Scaling: An approach that helps quantify personally relevant goals

60. Learning Objectives – What have you learned?
Describe how cognitive domains operate in daily life and offer examples of how impairments to cognitive domains interfere with functioning.
Describe the components of an initial cognitive consultation.
Describe how to interpret data across multiple sources to make treatment recommendations.
Describe the ingredients of selecting the right treatment for a client and offer specific examples of how client variables influence that decision.
Describe and demonstrate how to identify client-centered goals and desired outcomes and how to use goal-attainment scaling.
Identify the difference between session data and impact data and give examples of each.

61. References
Clinician's Guide to Cognitive Rehabilitation in Mild TBI: Application in Military Service Members and Veterans (In submission).  Rehabilitation and Reintegration Division, Office of the Surgeon General, United States Army.
Sohlberg, M. M. & Ledbetter, A. K. (2016). Management of Persistent Cognitive Symptoms After Sport-Related Concussion. American Journal of Speech-Language Pathology, 25, DOI: /2015_AJSLP
Sohlberg, M. M., & Mateer, C. A. (2001). Cognitive rehabilitation: An integrative neuropsychological approach. New York: Guilford Press.
Sohlberg, M. M., & Turkstra, L. S. (2011). Optimizing cognitive rehabilitation. New York: Guilford Press.