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Filling in the Gaps: Margaret A. Struchen, PhD

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  • Social isolation -- Rappaport et al (1989); Thomsen (1974) Network -- Kozloff (1987) Unemployment -- Brooks et al (1987); Dikmen et al (1994)
  • Major obstacle -- no accepted standard procedure for assessing Traditional Neuropsychological assessment does not directly assess social competence - contributes to possible explanation of cogn processing deficts Traditional Speech language eval - aspects of language less likely to be impacted by TBI ; more focus on pragmatics now, but still not much std. Method Traditional self-report inventories can be problematic for adults with TBI -- behavioral methods preferred Range of deficits variable -- subtle (mild difficulty with staying on topic) to pervasive (described by family as having “different personality”)
  • Communication and Personal appearance: SOCIAL COMMUNICATION Cognition (social knowledge, social cognition): COGNITION (broader def.) Knowledge of self: AWARENESS/SELF-EVALUATION (static and dynamic) Social Environment: SOCIAL ENVIRONMENT (context)
  • Sensory input received from environment & is then processed ------ -----cognitive abilities involved in processing social communication relies on basic cognitive processing : recepting, processing, expressive abilities back and forth between basic cognitive functioning and social communication Awareness/self-evaluation: meta-cognitive all takes place in social environment:
  • Molar versus molecular versus micro Discourse analysis: lots of info on specific linguistic aspects, not clinically feasible, unclear relationship to social integration.
  • NBRS - not specific to social communication skills
  • FAB - unilateral brain damage 2ndary to stroke IERB - tbi AIPSS - schizophrenia
  • BRISS - heterosocial skills/social anxiety

Filling in the Gaps: Margaret A. Struchen, PhD Filling in the Gaps: Margaret A. Struchen, PhD Presentation Transcript

  • Filling in the Gaps: Margaret A. Struchen, PhD Baylor College of Medicine TIRR (The Institute for Rehabilitation and Research) The Importance and Challenges of Measuring Social Communication Abilities following Traumatic Brain Injury.
  • Research Team
    • Angelle M. Sander, Ph.D.
    • Charles F. Contant, Ph.D.
    • Laura Rosas, M.A.
    • Patty Terrell Smith, B.S.
    • Diana Kurtz, B.A.
    • Monique Mills, B.S.
    • Allison N. Clark, M.A.
    • Analida Hernandez Ingraham, B.S.
    • This work was supported by funds from the National Institute on Disability and Rehabilitation Research in the Office of Special Education and Rehabilitative Services in the U.S. Department of Education.
    • (Grant #:H133G010152)
  • Objectives
    • Learners will become familiar with the impact of social communication abilities on functional outcomes for persons with traumatic brain injury and their families.
    • Learners will understand the challenges inherent in developing clinical useful assessment tools to measure social communication abilities.
    • Learners will be able to describe 3 tools that can be used for measuring social communication abilities following TBI.
  • Importance of Problem
    • Estimated incidence TBI
      • 1.4 million persons each year. (Langlois et al., 2004)
        • 50, 000 die
        • 235, 000 hospitalized
        • 1.1 million treated and released from ED
    • Disability related to TBI
      • 5.3 million persons with traumatic brain injury have a long-term or lifelong need for help to perform activities of daily living (Thurman et al., 2001)
      • About 40% of those hospitalized with TBI have at least one unmet need for services one year post-injury. (Corrigan et al., 2004)
    • Cost related to TBI
      • Estimated direct and indirect costs totaled an estimated $56.3 billion in the United States in 1995 (Thurman, 2001)
  • Importance of Problem
    • Social isolation has been frequently reported
    • Social network size shown to decrease with time, increased reliance on family for emotional support and leisure
    • High rates of unemployment 1-10 years post-injury.
    • Decreased productivity and social isolation can have a negative impact on quality of life and on emotional functioning of persons with TBI
    • Impairment in social skills is a common occurrence following TBI
    • Contributes to both decreased productivity and social isolation following TBI
    • Adequate assessment
      • Important step to develop empirically-based treatments
      • Identification of areas of functional impairment
    Importance of Problem
    • Holland (1977) noted that individuals with certain classic forms of aphasia “communicate” better than they talk.
    • Sohlberg & Mateer (1989) point out that the converse might be said of individuals with TBI: they talk better then they communicate.
    Social Communication
  • “ If someone were to read uncritically, he or she would get the impression that social skills deficits are at the core of a vast majority of behavioral dysfunctions.” Bellack, 1979
  • Terminology and Fields
    • Pragmatics (SLP/Linguistics)
    • Discourse Processes (SLP/Linguistics)
    • Functional Communication (SLP)
    • Social Problem Solving (Beh/Clin Psych)
    • Social Skills (Beh/Clin Psych)
    • Communicative Competence (Communication)
    • Social Communication Abilities
  • Definition
    • Social skills are the abilities to :
    “ Express both positive and negative feelings in the interpersonal context without suffering consequent lack of social reinforcement. Such skill is demonstrated in a a large variety of interpersonal contexts and involved the coordinated delivery of appropriate verbal and nonverbal responses. In addition, the socially skilled individual is attuned to the realities of the situation and is aware when he is likely to be reinforced for his efforts.” Hersen & Bellack, 1977
  • What are we talking about?
    • Social skills involve general interpersonal competencies as well as specific skills.
    • Involves communication behaviors –
      • Verbal
      • Nonverbal
    • Must be addressed in relation to specific contexts and communication partners.
  • Models of Social Communication
    • McFall (1982) - Information processing model - included 3 stages:
      • Decoding : reception, perception, interpretation
      • Decision: response search, response test, response selection, repertoire search
      • Execution: execution, response, judgment
    • Wallace (1980) - Receiving-Processing-Sending
    • Ylvisaker et al. (1992) - 5-factor model of social skill:
      • Communication Cognition Personal Appearance Knowledge of self Social Environment
  • Sensory Input Cognitive Abilities Social Environment Social Communication Receptive Processing Expressive Awareness/Self-Evaluation
  • Impact on Outcomes
    • Emotional, social, and behavioral impairments more predictive of participant restriction following TBI than cognitive or physical impairments.
    • Such factors have been found to impact:
      • Friendships and social integration
      • Vocational Outcome
      • Perceived caregiver stress/burden
  • Recurring Themes (Morton & Wehman, 1995)
    • Reduction in friendships and social support.
    • Lack of social opportunities to make new friendships.
    • Reduction in leisure activities.
    • Anxiety and depression found in large number, remains for prolonged period.
  • Social Skills & Social Integration
    • Weddell et al. (1980):
      • Sample: 31 men, 13 women with severe TBI > 2 yrs. post-injury
      • Measure: Semi-structured interview (multiple constructs)
      • Findings :
        • Almost half had limited or no social contacts, few leisure interests 1-yr post-injury
        • Those with “personality change” significantly less likely to return to work, had fewer interests, more frequently bored, more dependent on family
        • Also, quality of friendships changed to more casual acquaintances.
    • Lezak (1987):
      • Sample: 42 men with varying degrees of injury severity – longitudinal study with 6 timepoints (every 6 months)
      • Measure: Portland Adaptability Inventory
      • Findings: Social dislocation and isolation continuing pattern over time in spite of some emotional and personality improvements (90% with problems with social contact at all timepoints)
  • Social Skills & Social Integration
    • Bergland & Thomas (1991):
      • Sample: 12 adults with TBI (injury sustained in adolescence)
      • Measure: Global ratings via structured interview
      • Findings:
        • 92% of family members and persons with TBI reported that person with TBI had changes in friendships
        • 75% reported difficulty with making new friends.
  • Social Skills & Social Integration
    • Snow et al. (1998):
      • Sample:
        • 24 persons with severe TBI
        • Assessed 3-6 months and at 2 years post-injury
      • Measure: Discourse analysis
      • Findings: Discourse measures related to:
        • Social integration as measured by CHART at follow-up.
        • Executive functioning/verbal memory as measured by FAS, Trails, and RAVLT.
  • Social Skills & Employment
    • Brooks et al. (1987):
      • Sample:
        • 134 persons with TBI
        • 2-7 yrs. post-injury
        • >6 hrs. coma and/or >48 hrs PTA
      • Measure: Responses of family members to structured interview (communication composite - 10 items)
      • Findings: Conversational skills major predictor of failure to return to work following severe TBI, in addition to personality problems, behavioral disorders, and cognitive status.
  • Social Skills & Employment
    • Sale et al. (1991) :
      • Sample: 29 persons employed (M = 5.8 mos.) and then separated from job
      • Measure: Qualitative approach
        • Identification of reasons for separation
        • Sorting by “experts” into themes
      • Results: Most common cause of job separation: interpersonal difficulties, social cue misperception, inappropriate verbalization.
    • Wehman et al. (1993) :
      • Sample: 39 persons with severe TBI referred to supported employment program
      • Measure: Ratings by employment specialists using Client Employment Screening Form
      • Findings:
        • Those difficult to employ and maintain jobs were those working in positions that required frequent work-related interactions.
        • Communication problems included: repeatedly asking for assistance, responding inappropriately to nonverbal social cues, and exhibiting unusual or inappropriate behaviors.
    Social Skills & Employment
    • Godfrey et al. (1993):
      • Sample: 66 severe TBI assessed 6 mos.-3 yrs. post
      • Measures:
        • Informant rating scale
        • Behavioral measure of social skills functioning (behavioral rating of videotaped social interaction).
      • Findings:
        • Persons with TBI that failed to return to work were rated by informants as displaying significantly more adverse personality changes
        • Rated by trained judges to be significantly less socially skilled.
    Social Skills & Employment
  • Social Skills & Family Burden
    • Thomsen (1974;1984):
      • Sample: 50 adult severe TBI, 40 of that group at f/u
      • Measures: Structured interview
      • Findings:
        • Personality changes overshadowed cognitive and neurophysical function as determinants of family burden.
        • Loneliness is greatest difficulty after TBI.
    • Brooks & Aughton (1979):
      • Sample: 35 adult TBI, 35 family members
      • Measures: Objective and Subjective Burden scales
      • Findings: Behavioral and emotional changes outranked cognitive changes in contributing to family burden.
    • Numerous studies replicate these findings .
      • Communicative, behavioral, personality changes assessed by questionnaire/interview
  • Social Skills & Family Burden
    • Godfrey et al. (1991):
      • Sample:
        • 18 community-dwelling persons with severe TBI
        • At least 8 months post-injury
        • Family member
      • Measure: Behavioral measurement of social skill with videotaped interaction of person with TBI and family member.
      • Findings:
        • Less socially skilled person with TBI showed less positive affect and required more effort from family member
        • Interpreted as greater family burden.
  • Summary
    • Body of literature provides basis for hypothesizing that social communication functioning will account for a significant portion of variance in functional outcome.
    • Most studies with indirect evidence: measure emotional functioning, personality functioning, behavioral functioning.
    • For those which directly measure social skills/communication, most have used assessment instruments designed to measure a broad range of symptoms following TBI.
      • Self-report questionnaires with multiple physical, cognitive, emotional, behavioral areas addressed.
      • Structured interview (often with social communication only a part)
    • Exception, work in New Zealand and Australia using behavioral measures.
    • Systematic and comprehensive examination of social skills has not been conducted in most research in TBI.
    • Many studies examine “psychosocial status, communication skills, emotional functioning, social skills, and related constructs” via a single item or group of items contained on self- or other-report measures.
    • Several studies have examined social communication skills by using discourse analysis.
    • Limitations global/micro measures for application to clinical setting.
    • Clinically, many rely on behavioral observation without structured rating scales, on clinical interview, and on self- or other-report questionnaires.
    Gaps
  • How do you measure social communication?
  • Methods
    • Aphasia Batteries or subtests
    • Functional Communication Batteries
    • Interview
    • Self/Other-Report Questionnaire
    • Behavioral Observation
    • Discourse Analysis
    • Role Play
  • Aphasia Batteries
    • Studies of large TBI populations found classic language disorders relatively rare
    • Parallel interest in measuring /disability handicap
      • move to focus on effects of cognitive and psychosocial skills on outcomes
  • Functional Communication Batteries
    • Developed from 1960s onward
    • Designed for use by speech language therapists, limited use by other professionals.
    • Inclusion of complex terminology (e.g., speech act pair analysis, turn-taking contingency)
    • Examples:
      • Functional Communication Profile (Sarno, 1969)
      • Pragmatics Profile of Early Communication Skills (Dewart & Sumner, 1988)
      • Profile of Communicative Appropriateness (Penn, 1985)
  • Interview
    • Despite lack of convincing evidence of reliability or validity – interview is most frequently used method of assessment.
    • Standard problem-oriented behavioral interview (antecedents, behaviors, consequences):
      • Frequency of social interaction
      • Person’s level of satisfaction with frequency
      • Quality of social interaction
      • Description of satisfactory/unsatisfactory occasions
      • Extent to which person believes their behavior contributed to such outcomes
      • Description of own behaviors that were instrumental in determining such outcomes.
  • Self/Other-Report Questionnaire
    • Vast number of self-report questionnaires developed for other populations are available.
      • Social anxiety (e.g., Social Avoidance and Distress Scale)
      • Assertiveness (e.g., Assertion Inventory)
      • Interpersonal behaviors (e.g., Dating and Assertion Questionnaire)
    • Questionnaires designed for use with TBI.
      • Frontal Lobe Personality Scale (FLOPS)
      • Dysexecutive Questionnaire (BADS)
      • La Trobe Communication Questionnaire (Douglas et al., 2000)*
  • Behavioral Observation
    • Gold Standard for psychological assessment.
    • Use of rating scales/coding systems in various populations.
      • Heterosocial Skills Behavioral Checklist
      • Social Interaction Test
    • Molar vs. Molecular
    • Intermediate level of analysis involved with behavioral assessment:
      • Provides depth of information to identify target behaviors
      • Provides format that is practical to administer in a clinical setting.
    • Despite these advantages, relatively few studies have utilized such behavioral assessment.
  • Rating Scales
    • Neurobehavioral Rating Scale (Levin et al., 1987): rating scale assessing behavioral symptoms in persons with TBI
    • Pragmatics Protocol (Prutting & Kirschner, 1983): measures 32 pragmatics skills rated in terms of appropriateness
    • Communication Performance Scale ( Erlich & Sipes, 1985): adapted from Pragmatics Protocol and rates 13 behaviors;
    • (Erlich & Barry, 1989) - 9-point ratings of 6 behaviors.
    • Behaviorally Referenced Rating System of Intermediate Social Skills (BRISS) (Wallenger et al, 1985).: Intermediate level coding of 11 specific behavioral components (5 verbal/6 nonverbal) rated on 7-pt. Scale
    • Profile of Functional Impairments in Communication (PFIC): (Linscott, Knight, & Godfrey, 1996): Rating on 10 communication rules and specific behavior items.**
  • Discourse Analysis
    • Discourse Analysis is concerned with how language users produce and interpret language in situated contexts and how these constructions relate to social and cultural norms, preferences, and expectations.
    • It focuses on how lexico-grammar and discourse systematically vary across social situations and at the same time help to define those situations.
    • Research in discourse analysis seeks to:
        • analyze the linguistic structures of different discourse genres
        • describe conversational sequences
        • examine speech activities
        • describe oral and literate registers
        • analyze stance
    • (UCLA Department of Applied Linguistics & TESL)
  • Role Play Assessments
    • Examples:
      • Behavioral Assertion Test – Revised (Eisler et al., 1975)
      • Assessment of Interpersonal Problem-Solving Skills** (Donahoe et al., 1990)
      • Simulated Social Interaction Test (Curran et al., 1980; Curran, 1982)
    • Vary by Social Behaviors Assessed
      • Assertiveness
      • Social Skills description, solution generation, and enactment
      • Social Skill and anxiety
  • Challenges
    • Definitional Issues
    • Comprehensiveness
    • Clinical Feasibility
    • Variance in “Normal” Population
    • Contextual Issues
  • Definitional Issues
    • Various disciplines
      • SLP
      • Linguistics
      • Psychology
    • Different terminologies
      • Clarity and collaboration
  • Comprehensiveness
    • Models of social communication
      • Receptive
      • Processing
      • Sending
    • Most measures utilized focus on expressive or sending aspects
    • How are we addressing receptive/processing social communication skills?
  • Clinical Feasibility
    • Instruments must be:
      • User-friendly
      • Reliable
      • Timely
      • Portable ?? (for context)
    • Reliable
      • Interrater
      • Test-Retest
      • Internally consistent
  • Variance in “Normal” Population
    • Great challenge – enormous diversity of “normal” performance.
      • Community
      • Context
    • Insufficient normative data on virtually all measures utilized.
  • Addressing Context
    • Outpatient NP clinic setting - limited flexibility to address context
      • Role-play
      • Varied communication samples
    • Rehabilitation setting or ongoing treatment setting – can address with different communication partners, settings, and situations.
      • Portability of rating scales like PFIC are useful
  • RESEARCH PARTICIPANTS
    • Participants with TBI:
    • 123 adults with TBI recruited from participants in TIRR TBI Model System study.
      • Acute medical care at Level One Trauma Center (BTGH or Hermann Hospital)
      • Inpatient rehabilitation at TIRR
    • Complicated Mild to Severe TBI
    • > 18 years of age
    • > 1 year post-injury
    • Informed consent and release of medical records to document TBI.
    • Exclusionary Criteria:
      • Age < 18 years
      • Pre-existing neurological disorder affecting cognitive functioning (e.g., stroke, dementia, etc.)
      • Pre-existing severe psychiatric disorder (e.g., schizophrenia, bipolar disorder, etc.)
    • Controls:
      • Matched by age, education, and gender
    • Family/Friend:
      • LCQ Other form; Q’aires on life satisfaction, stress, caregiver appraisal
    RESEARCH PARTICIPANTS
  • Measures of Social Communication:
    • Receptive Aspects :
      • FLORIDA AFFECT BATTERY (FAB)
      • ASSESSMENT OF INTERPERSONAL PROBLEM SOLVING SKILLS (AIPSS)
    • Processing Aspects :
      • ASSESSMENT OF INTERPERSONAL PROBLEM SOLVING SKILLS (AIPSS)
    • Expressive Aspects :
      • ASSESSMENT OF INTERPERSONAL PROBLEM SOLVING SKILLS (AIPSS)
      • PROFILE OF FUNCTIONAL IMPAIRMENTS IN COMMUNICATION (PFIC)
      • DICE GAME (DICE)
    • Questionnaire:
      • LATROBE COMMUNICATION QUESTIONNAIRE (LCQ)
  • Receptive Aspects
    • Florida Affect Battery (Bowers et al., 1991) :
      • Affect Discrimination
      • Affect Selection
      • Matching Affect
      • Emotional Prosody Discrimination
      • Conflicting Prosody
      • Matching Prosody to Emotional Face
    • Assessment of Interpersonal Problem Solving Skills:
      • Problem Identification
  • Florida Affect Battery (N=71) *** *** *** *** *** ***p < .0001
  • Processing Aspects
    • Assessment of Interpersonal Problem Solving Skills (Donahoe et al., 1990) :
      • Generation of problem-solving solutions
  • Expressive Aspects
    • Assessment of Interpersonal Problem Solving Skills (Donahoe et al., 1990) :
      • Quality of verbal skills
      • Quality of nonverbal skills
      • Overall quality of response
    • Profile of Functional Impairments in Communication (Linscott, Knight, & Godfrey, 1996) :
      • Rating on 10 communication rules and 85 specific behavior items.
    • Dice Game (McDonald & Pierce, 1995) :
      • Inclusion of essential propositions
      • Efficiency of procedural sample
  • Social Communication Self/Other-Ratings:
    • LaTrobe Communication Questionnaire
    • (Douglas, O’Flaherty, Snow, 2000)
      • When talking to others, do you (does your family member)…
        • Leave out important details?
        • Say or do things others might consider rude or embarrassing?
        • Hesitate, pause, or repeat self?
        • Have difficulty getting the conversation started?
      • Rating:
        • Never or rarely
        • Sometimes
        • Often
        • Usually or always
  • La Trobe Communication Questionnaire (N=71) * * ** * p < 0.05, ** p < 0.01
  • Questions?
  • References
    • Bellack, AS. (1979). A critical appraisal of strategies for assessing social skills. Behavioral Assessment, 1, 157-176.
    • Bergland MM, Thomas KR. (1991). Psychosocial issues following severe head injury in adolescence: Individual and family perceptions. Rehabilitation Counseling Bulletin, 35(1), 5-22.
    • Bowers, D, Blonder, LX, Heilman, KM, (1991). The Florida Affect Battery . Center for Neuropsychological Studies – University of Florida.
    • Brooks DN, Aughton ME. (1979). Psychological consequences of blunt head injury. Journal of Rehabilitation Medicine, 1, 160-165.
    • Brooks, DN, McKinlay, A, Symington, C, et al. (1987). Return to work within the first seven years of severe head injury. Brain Injury, 1, 5-19.
    • Corrigan JD, Whiteneck G, Mellick, D. (2004). Perceived needs following traumatic brain injury. Journal of Head Trauma Rehabilitation, 19(3), 205-216.
    • Donahoe CP, Carter MJ, Bloem WD, Hirsch GL, Laasi N, Wallace CJ. (1990). Assessment of interpersonal problem solving skills. Psychiatry, 53(4) ,:329-39.
    • Douglas JM, O’Flaherty CA, Snow PC. (2000). Measuring perception of communicative ability: The development and evaluation of the La Trobe Communication Questionnaire. Aphasiology, 14, 251-268.
  • References (cont.)
    • Godfrey HPD, Knight RG, Bishara SN. (1991). The relationship between social skill and family problem-solving following very severe closed head injury. Brain Injury, 5, 207-211.
    • Godfrey HPD, Partridge FM, Knight RG, et al. (1993). Course of insight disorder and emotional dysfunction following closed head injury. Journal of Clinical and Experimental Neuropsychology, 15, 503-515.
    • Holland AL. (1977). Comment on &quot;spouses understanding of the communication disabilities of aphasic patients&quot;. Journal of Speech & Hearing Disorders. 42(2), 307-310.
    • Langlois JA, Rutland-Brown, Thomas KE. (2004). Traumatic brain injury in the United States: Emergency department visits, hospitalizations, and deaths. Atlanta (GA): Centers for Disease Control and Prevention, National Center for Injury Prevention and Control.
    • Lezak M. (1987). Relationships between personality disorders, social disturbances, and physical disability following traumatic brain injury. Journal of Head Trauma Rehabilitation, 2(1), 57-69.
    • Linscott RJ, Knight RG, Godfrey HPD. (1996). The Profile of Functional Impairemtn in Communication (PFIC): A measure of comunication impairment for clinical use. Brain Injury, 10, 111-123.
  • References (cont.)
    • McDonald S, Pierce S. (1995) The dice game: A new test of pragmatic skills after closed head injury. Brain Injury, 9(3), 255-271.
    • McFall RM. (1982). A review and reformulation of the concept of social skills. Behavioral Assessment, 4, 1-33.
    • Morton MV, Wehman P. (1995). Psychosocial and emotional sequelae of individuals with traumatic brain injury: A literature review and some recommendations. Brain Injury, 9, 81-92.
    • Sale P, West M, Sherron P, et al. (1991). Exploratory analysis of job separations from supported employment for persons with traumatic brain injury. Journal of Head Trauma Rehabilitation, 6(3), 1-11.
    • Snow PC, Douglas J, Ponsford J. (1998). Conversational discourse abilities following severe traumatic brain injury: A follow-up study. Brain Injury, 12, 911-935.
    • Sohlberg MM, Mateer, CA. (1989). Introduction to Cognitive Rehabilitation. New York: Guilford Press, p. 214.
    • Thomsen, IV. (1974). The patient with severe head injury and his family. Scandinavian Journal of Rehabilitation Medicine, 6, 180-183.
    • Thomsen, IV. (1984). Late outcome of very severe blunt trauma: a 10-15 year second follow-up. Journal of Neurology, Neurosurgery, and Psychiatry, 47, 260-268.
  • References (cont.)
    • Thurman D. (2001). The epidemiology and economics of head trauma. In: Miller L, Hayes R (Eds.) Head Truama: Basic, Preclinical, and Clinical Directions. New York: Wiley & Sons.
    • Thurman D, Alverson C, Dunn K, et al. (1999). Traumatic brain injury in the United States: A public health perspective. Journal of Head Trauma Rehabilitation, 14(6 ), 602-615.
    • Wallace CJ, Nelson CJ, Liberman RP, et al. (1980). A review and critique of social skills training with schizophrenic patients. Schizophrenia Bulletin, 6, 42-63.
    • Weddell R, Oddy M, Jenkins D. (1980). Social adjustment after rehabilitation: A two-year follow-up of patients with severe head injury. Psychological Medicine, 10, 257-263.
    • Wehman P, Kregel J, Sherron P, et al. (1993). Critical factors associated with the successful supported employment placement of patients with severe traumatic brain injury. Brain Injury, 7(1), 31-44.
    • Ylvisaker M, Urbanczyk B, Feeney, TJ. (1992). Social skills following traumatic brain injury. Seminars in Speech and Language, 13(4), 308-322.
    • Margaret A. Struchen, Ph.D.
    • Brain Injury Research Center/TIRR
    • 2455 S. Braeswood
    • Houston, TX 77030
    • (713) 666-9550
    • [email_address]
    • [email_address]
    www.tbicommunity.org