1997 Conference Proceedings

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Julie Brunings MS,CCC-SLP
Memorial Transitional Rehab Services
2085 3rd Street
Long Beach, CA 90814
FAX (310)434-2540 Michelle Parolise, MBA,OTR

Memorial Transitional Rehab Services
2085 3rd Street
Long Beach, CA 90814
FAX (310)434-2540

Issues regarding return to work are often major concerns for patients participating in post-acute rehabilitation following traumatic brain injury. Patients who have progressed to independent levels in self care, homecare, and routine community living tasks frequently continue to lack the higher level cognitive skills required for returning to competitive employment. It became evident that specific programs addressing higher level cognitive skills needed to be developed with the goal of vocational training.

In an attempt to develop programs that would provide successful learning experiences, multiple variables were considered. These variables involved developing a continuum of difficulty which would motivate and facilitate performance, establishing effective schedules of reinforcement, and training patients to generalize skills of practical value following discharge from a treatment program.

A continuum of difficulty first takes into consideration the barriers to learning imposed by brain injury. Cognitive problems frequently associated with brain injury include deficits in attention, memory, reasoning and organization. Because of this range of deficits, treatment tasks should be flexible and presented at levels which meet the patient's cognitive abilities. As the cognitive skills required to complete one level are mastered, these skills should be built upon with more complex cognitive demands at future levels. Patients should progress through these levels sequentially at a rate equivalent to current information processing abilities (Wood, 1989).

Second, a continuum of difficulty should allow for the management of frustration by providing tasks which incorporate appropriate levels of challenge with opportunity for success and positive feedback. Tasks which are too simple can lead to boredom and tasks which are too difficult can lead to frustration. Tasks which are challenging yet attainable facilitate interest and improve performance.

In evaluating how to manage frustration and best teach skills to brain injured patients, a comparison was made to teaching children to read. To effectively teach children to read, accuracy in word recognition should be at the following levels: Independent reading 98-99% recognition of all words, instructional reading 95% recognition of all words, and frustration level 90% recognition of all words (Dechant, 1982). In teaching new skills, teachers should seek instructional level materials which avoid reaching frustration levels Durkin, 1972). Managing frustration when teaching new tasks to the brain injured patient is extremely important. These persons, already concerned about their performance, are frequently aware that they are being challenged by tasks they once considered simple. Therefore, it is important to train clients at a level of difficulty where task completion is at 95% or greater accuracy.

A flexible, rewarding, and understandable schedule of reinforcement also needs to be present.

Reinforcement consists of feedback regarding the accuracy of performance coupled with social praise. In the initial stages of learning, feedback should be provided on a continuous schedule. This frequent feedback is effective in assisting the person acquire a new skill. As the person progresses, the schedule of reinforcement should change to a fixed ratio to assist with consolidation of the new learning. This fixed ratio schedule of reinforcement is both more practical and less resistive to extinction than continuous reinforcement. Finally, as a person gains skill and confidence, constant or intermittent reinforcement in no longer as important and feedback can be provided in random intervals determined by the therapist. This variable rate of reinforcement is more reflective of the type of reinforcement provided in "real world" situations and is more effective in mainlining and generalizing the learned skill (Jacobs, 1993).

However, for a vocational training program to have practical significance, the brain injured patient must be able to generalize the skills learned in the clinical environment to the work environment. Brain injured patients have difficulty transferring learned skills from one situation to another. In an effort to increase generalization in a limited time frame, a program should focus on skill building rather than process training (Wood, 1989; Wilson, 1989; Ponsford, 1990). Patients should be given frequent opportunity to practice these skills until they become habitual and generalized (Wood, 1989).

Based upon the goal of providing vocational training to patients with mild to moderate brain injury, two programs were developed to assess and treat cognitive skills utilized in a work environment. Since computers are so prevalent in the workplace, these cognitive skills could be addressed in functional and meaningful tasks to the patient. The programs developed were created using Excel version 5.0 for windows. They were designed to utilize common concepts which were present in the work place as well as address common cognitive impairments secondary to mild to moderate brain injury. The basic workplace concepts selected involve the use of computers to track accounts payable and accounts receivable. The programs were therefore named: Accounts Payable and Accounts Receivable. These concepts were then broken down into tasks designed in a hierarchy to address the various levels of ability along the rehabilitation continuum. The programs were divided into three basic levels with sublevels within each that are also based upon a hierarchy.

Level I of each program assesses and focuses upon basic cognitive skills such as sustained and selective attention, short term memory with use of strategies such as repetition and visual cues, and visual scanning. For the first program, "Accounts Payable," the patient must look at the name of a company on the computer screen and then find the corresponding bill from that company. The patient must sustain attention to this and then locate the amount due on the bill. Finally, the patient must input that number into the correct column of the spreadsheet. For the second program, "Accounts Receivable," the patient must look at a check, encode the name of the customer, and then scan the spreadsheet to locate that customer. The patient must then enter the amount from the check into the appropriate cell of the spreadsheet. The program also addresses basic level reasoning skills necessary to match names that may not be exactly the same (e.g. it may be one name on the computer and two names on the check).

Level I is further broken down to provide feedback at different levels. The initial level provides feedback following every three entries. However, to receive this feedback, the patient must sustain attention to determine of the new subtotal matches the feedback subtotal. As the patient becomes more proficient, feedback levels can be upgraded to every five entries, ten entries, or at the end of the task. Therefore, the therapist can determine at which rate the patient needs to receive feedback and reinforcement as to their accuracy to provide appropriate feedback schedules.

Level II builds upon the skills mastered at Level I such as sustained and selective attention. It then adds additional components to which the patient must scan and attend to increase overall complexity. This level also begins to address higher level reasoning skills to determine which aspects of the documents or the spreadsheet sheet are appropriate. At Level II, "Accounts Payable" requires that the patient enter all of the important information onto the spreadsheet. Information includes company name, account number, date received, date due, and amount due that is determined from the bills. On several of the bills, the information is vague and the patient must deduce what would be the most probable response for the category heading.

Level II of "Accounts Receivable" is even more complex. It too builds upon the skills mastered at Level I as well as additional cognitive skills addressed in the rehabilitation hierarchy. Specifically, it requires increased selective attention as well as introducing divided attention to scan multiple documents for information. It also places increased demands upon short term memory and strategies to compensate for loss in this area as the patient must encode the information found on one document that needs to correspond with information on another document or on the computer screen. For this program the patient must enter the amount paid for each customer from the checks and then must also scan another spreadsheet printout to determine the amounts that are past due for each customer.

Finally, at Level III, the patient builds upon previous cognitive skills of selective and sustained attention, memory and memory strategies, scanning, and simple high level reasoning and organization. The demands of these skills are increased and additional skills are introduced to again increase overall complexity. These cognitive skills include higher level deductive reasoning and organizational skills necessary in most competitive employment settings. "Accounts Payable" requires that the patient first organize the bills in chronological order according to date due. It then asks the patient to prioritize which bills should be paid based upon a budget and various predetermined criteria (e.g. if the gas is not paid within 30 days it will be shut off, a 1% charge will be added to late payment of phone bill, etc.).

For "Accounts Receivable," Level III reinforces the cognitive skills addressed previously by instructing the patient to complete the same steps indicated for Level II. It then begins to address increasingly complex higher level reasoning and organization skills by requesting that the patient generate a report to indicate which customers' accounts are past due and to organize it based upon how many months the account is past due. This task requires that the patient preplan how the report will be created and should review possibilities with the therapist.

As mentioned for Level I, Level II can also be broken into sublevels to provide feedback at appropriate levels for the patient. However, once the patient reaches Level III in which they must create a report, they must rely upon feedback from the therapist or the Rehab technician. At this point, it is important to have the patient discuss how they will organize and generate the report before they begin. Strategies may need to be developed by the therapist for organization and reasoning.

These programs were designed to be used by either a licensed therapist or by a Rehab technician. The programs ask for specific feedback from the technician to be provided to the therapist. This information can be used to develop strategies for these and other therapy tasks. The programs were also designed to facilitate increased independence in work skills for the patient. For example, when the program is being used at the various sublevels of reinforcement to rehearse these skills, the patient can work with less supervision or even independently.

The patients' feedback to these programs has been very positive up to this point and has been critical in modifications to the programs. The programs have been used both with patients who are familiar with computers and those who are not. Patients who are familiar with computers have demonstrated less difficulty with insight to how these skills would apply to their every day life than with conventional therapy tasks which address these same cognitive skills. They have also demonstrated an increased correlation of difficulties they experience with the computer tasks to those discussed as a result of the brain injury. Also, higher level patients who are not familiar with computers report that they enjoyed the challenge of learning something new and being able to practice difficult cognitive skills in a novel and non-threatening manner.

In summary, response to the programs has been good. However, use of these programs is still in the development and modification stage. Research needs to be conducted to determine objective treatment efficacy rates for these programs and to determine vocational outcomes that can be projected from these tasks. Also, based upon the positive response to these programs, future programs could be created to address other areas of cognitive rehabilitation and other computer areas utilized in the work place. Examples include programs to address using word processing skills, using a database to analyze data and get specific answers, and organizing reports for presentations.


Dechant, E. (1982). "Improving the Teaching of Reading, Third Edition." New Jersey: Prentice-Hall, Inc.

Durkin, D. (1972). "Teaching Young Children to Read," Boston: Allyn and Bacon, Inc.

Jacobs, H. (1993). "Behavior Analysis Guidelines and Brain Injury Rehabilitation," Maryland: Aspen Publishers, Inc.

Ponsford, J. (1990). "The Use of Computers in the Rehabilitation of Attention Disorders." In R. Wood & Fussy, I.(Eds), "Cognitive Rehabilitation in Perspective," Philadelphia: Taylor & Francis, Inc.

Wilson, B. (1989). "Models of Cognitive Rehabilitation." In R. Wood & P. Eames (Eds), "Models of Brain Injury Rehabilitation," London: Chapman and Hall Ltd.

Wood, R. (1989). "A Salient Factors Approach to Brain Injury Rehabilitation." In R. Wood & P. Eames (Eds), "Models of Brain Injury Rehabilitation," London: Chapman and Hall Ltd.

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