P ENÍNSULA I BÉRICA

A treatment for people with ABI needs to take a person’s cognitive ability into account, irrespective of the treatment content. Cognitive impairments are common, long-standing, and pervasive post-injury (Levin & Kraus, 1994; Prigatano, 1999; Sohlberg & Mateer, 2001), and can have an impact on treatment delivery, and the uptake or development of target skills (Anson & Ponsford, 2006b; Bornhofen & McDonald, 2008a; Cicerone et al., 2011). In particular, there may be impairments in memory, concentration, new learning, executive function, and awareness. Even if treatments are not intended to improve cognitive ability, treatments must accommodate a person’s existing cognitive ability, and make adjustments to the treatment in order for people to get the most benefit (Togher et al., 2014; Velikonja et al., 2014).

Several studies have provided practical suggestions on how to make such

accommodations. Difficulties with attention, concentration and fatigue can be overcome by limiting the duration of sessions to no more than 2 hours and incorporating frequent breaks (Hodgson, McDonald, Tate, & Gertler, 2005). Impairments in new learning and memory can be addressed by increasing the intensity of sessions, involving family members (Khan-Bourne & Brown, 2003), giving frequent repetitions of information, and using visual aids and session summaries (Hodgson et al., 2005; Ponsford, Sloan, & Snow, 1995). Elements of these were incorporated into project-based treatment with respect to session duration and structure, and use of supportive visual aids.

More recently, technologies have emerged to overcome impaired recall of treatment goals and session information. In particular, there has been an increase in the use of mobile assistive technologies to support cognition including good evidence for technologies that call attention to goals (Gillespie, Best, & O'Neill, 2012). Recall is

achievement (Miller & Rollnick, 2002). While studies have shown improved goal recall from a range of electronic devices (Dowds et al., 2011; Hart, Hawkey, & Whyte, 2002), these devices often require many hours of training (Svoboda, Richards, Leach, &

Mertens, 2012). Mobile phones address this problem, as they are commonplace, socially acceptable and unlikely to require training. Culley and Evans (2010) found that 11 people with TBI had better goal recall from daily text reminders of their goals compared to a group that did not receive text reminders. The only ‘training’ requirements were to make sure the goal could be understood and expressed in a single sentence, and that the person with brain injury knew how to receive and read a text. Text reminders prompt the person with ABI to remember and think about their goals and prompt engagement in goal-directed behaviour thus, reducing the need for clinician-led monitoring. Other studies have demonstrated the benefit of text-based systems as a reminder for specific information and/or to engage in specific behaviours (Fish et al., 2007; McDonald et al., 2011; Wilson, Emslie, Quirk, & Evans, 2001). This study incorporated frequent text reminders of a person’s goals, and homework-related tasks, sent to both the person with ABI and their communication partner, to help improve recall and completion of tasks.

Impaired executive function and limitations in goal-directed behaviour can effect recovery. These areas can be partially addressed by conducting sessions in a structured and routine format (Hodgson et al., 2005; Khan-Bourne & Brown, 2003). In addition, strategies that use step-by-step procedures, with metacognitive skills training, can also help to deal with impaired executive function (Cicerone et al., 2000; Cicerone et al., 2005; Cicerone et al., 2011; Kennedy et al., 2008). A systematic review of treatments for executive function (Kennedy et al., 2008) found that many studies use step-by-step procedures to improve everyday problem solving, which could be supported by visual scaffolds, such as the goal-obstacles-plan-do-review framework

(Ylvisaker, Sellers, & Edelman, 1998), or the traffic light system (Miotto, Evans, de Lucia, & Scaff, 2009). In addition, Chapter 3 highlighted that psychological treatments that give strategies to help improve a person’s ability to self-monitor and self-regulate their skills, is important to improving QOL. Metacognitive skills training, which refers to improving a person’s ability to self-monitor, evaluate and regulate their performance on tasks, can be built into the step-by-step procedures described above (Cicerone et al., 2011; Kennedy et al., 2008; Ponsford et al., 2014). This training helps to build self- awareness, increase strategy use, and transfer and generalise skills to everyday situations (Cicerone et al., 2011; Kennedy et al., 2008; Ownsworth et al., 2008). Prigatano and Wong (1999) suggest that getting a person to predict and evaluate task performance should be emphasised for repeated tasks. Several studies have

demonstrated the positive effects of treatments that have included self-prediction and evaluation on goal achievement (Kreutzer, Stejskal, Godwin, Powell, & Arango- Lasprilla, 2010), self-regulation skills (Goverover, Johnston, Toglia, & Deluca, 2007; Ownsworth, McFarland, & Young, 2000), psychosocial functioning (Ownsworth et al., 2000) and functional task performance (Goverover et al., 2007; Ownsworth, Fleming, Desbois, Strong, & Kuipers, 2006; Ownsworth, Quinn, Fleming, Kendall, & Shum, 2010). More recently, the use of metacognitive skills training has been advocated for working with people with ABI with communication impairments (Togher et al., 2014). The use of a structured session, visual scaffold for problem solving, and metacognitive skills training for tasks within sessions and working on goals, was built into the design of project-based treatment as a result.

Treatments for people with ABI need to address impaired awareness, which can affect response to treatment (Cicerone et al., 2000; Cicerone et al., 2005; Cicerone et al., 2011; Fleming, Strong, & Ashton, 1998; Ownsworth et al., 2008; Ownsworth et al.,

2000; Prigatano & Wong, 1999; Thomas, 2004). Impaired awareness or impaired acceptance of difficulties can reduce the motivation to engage in treatment, i.e. there may be poor compliance with strategies and techniques to remediate impairments if the person with ABI does not acknowledge that those impairments exist (Fleming et al., 1998; Katz, Fleming, Keren, Lightbody, & Hartman-Maeir, 2002; Sohlberg & Mateer, 2001; Trahan, Pépin, & Hopps, 2006). As a result, treatment approaches need to reflect the underlying cause of a person’s impaired awareness whether it is neurocognitive, psychological or socio-environmental (Fleming & Ownsworth, 2006). For example, if the underlying cause is neurocognitive, then approaches may include selecting key tasks to develop awareness, providing clear feedback and opportunities for a person to

evaluate their performance and group therapy. In reality, a person with ABI may have a combination of contributing factors that require a range of treatment approaches that address impaired awareness. As a result, some people with ABI may respond more favourably to some treatments than others. As a result, a range of strategies that address awareness were incorporated into project-based treatment (e.g. non-confrontational treatment environment, video-taping, feedback, involvement of communication partners).