asha tbi assessment


Retrieved from Knowledge translation in ABI rehabilitation: A model for consolidating and applying the evidence for cognitive-communication interventions. DePompei, R., Gillette, Y., Goetz, E., Xenopoulos-Oddsson, A., Bryen, D., & Dowds, M. (2008). Lorenzen, B., & Murray, L. L. (2008). For example, dysphagia management may include interdisciplinary teamwork between occupational therapists, dietitians, nursing staff, and the SLP. Adolescents with TBI performed below peers without brain injury on SFAVRES (Newsome et al., 2010). Sohlberg, M. M., & Turkstra, L. S. (2011). Commission on Accreditation of Rehabilitation Facilities. ), Social and communication disorders following traumatic brain injury (pp. Alzheimer Dis Assoc Disord. Mild traumatic brain injury (mTBI) has been in the news lately, particularly mTBI in school-aged children, professional athletes, and service members and veterans. Management and remediation of memory problems in brain-injured adults. See ASHA's Practice Portal page on Adult Dysphagia. carefully fading supports and prompts (Sohlberg et al., 2005; Sohlberg & Turkstra, 2011). (2012). Assistive technology for cognition following brain injury: Guidelines for device and app selection. See ASHA's Scope of Practice in Audiology (ASHA, 2018). It is a measure of. (2011). Journal of Medical Speech-Language Pathology, 15, xv–li. Predictors of cognitive function and recovery 10 years after traumatic brain injury in young children. Behavioral and social interventions for individuals with traumatic brain injury: A summary of the research with clinical implications. See the Screening section of the Traumatic Brain Injury (Adults) Evidence Map for relevant evidence, expert opinion, and client/patient perspective. Zaloshnja, E., Miller, T., Langlois, J. Audiologists play a central role in the assessment, diagnosis, and rehabilitation of hearing and vestibular deficits in children and adolescents with TBI. Worldwide, in 2016, there were approximately 27 million new cases of TBI with an age-adjusted incidence rate of 369 per 100,000—representing a 3.6% increase from 1990. Person- and family-centered care is a collaborative approach grounded in a mutually beneficial partnership among individuals, families, and clinicians. See ASHA's web page on interprofessional education/interprofessional practice (IPE/IPE) and ASHA's resource on collaboration and teaming. New York, NY: Guilford. Cognitive-communication treatments include the following: Instructional or teaching techniques used in cognitive-communication treatment include the following: Social communication interventions are designed (a) to improve functional conversational skills, including the use of appropriate pragmatic language norms (e.g., taking turns and remaining on topic) and (b) to help the individual with TBI navigate social situations. Russell, N. (1993). Ylvisaker, M., & Feeney, T. (2007). Cognitive rehabilitation. When selecting a standardized assessment tool, clinicians consider. Bethesda, MD: Author. Meulenbroek, P., Bowers, B., & Turkstra, L. S. (2016). Trends in concussion incidence in high school sports: A prospective 11-year study. Oberg, L., & Turkstra, L. (1998). In the United States alone, the Center for Disease Control estimates that there are approximately 5.3 million individuals living with TBI related disabilities. Albany, NY: Author. Infants and toddlers may lack the communication or developmental skills to overtly report the signs and symptoms of TBI noted above. Compensatory approaches focus on adapting to deficits by learning new or different ways of doing things to minimize difficulties (National Institutes of Health [NIH], 1998). (2018). (2011). Do classroom accommodations or task modifications help maximize the student's academic performance? Traumatic Brain Injury section of the Pediatric Brain Injury Evidence Map, Interprofessional Education/Interprofessional Practice (IPE/IPP), assessment tools, techniques, and data sources, Speech Sound Disorders: Articulation and Phonology, Augmentative and Alternative Communication, selecting technology or related treatment products, ASHA Leader, New mTBI Guidelines for Young Children: What Do They Mean, Current Perspectives on Traumatic Brain Injury, Evaluating and Treating Communication and Cognitive Disorders: Approaches to Referral and Collaboration for Speech-Language Pathology and Clinical Neuropsychology, Patient Information Handouts: Audiology Information Series, Tinnitus Evaluation and Management Considerations for Persons With Mild Traumatic Brain Injury, Traumatic Brain Injury: A Primer for Professionals, Traumatic Brain Injury [Consumer Information], American Congress of Rehabilitation Medicine (Brain Injury Resources, Brain Injury Association of America (BIAA), The Center on Brain Injury Research & Training, Project BRAIN (Brain Resource and Information Network), Report to Congress on the Management of TBI in Children, The Sarah Jane Brain Project/National Pediatric Acquired Brain Injury (PABI) Plan,,,,,,root,regs,300,A,300%252E8,c,12,, /Articles/Tinnitus-Evaluation-and-Management-Considerations-for-Persons-with-Mild-Traumatic-Brain-Injury/,,, Connect with your colleagues in the ASHA Community, In the United States, approximately half a million children ages 0–14 years (. Traumatic brain injury in the United States: A report to Congress. Strategic learning intervention is the ability to organize, combine, and synthesize details from texts, lectures, or conversations in order to abstract the most important concepts. Return to academics protocol after concussion/mild TBI. After hospital: Working with schools and families to support the long term needs of children with brain injuries. This list is not exhaustive, and inclusion of any specific treatment approach does not imply endorsement by ASHA. Kennedy, M. R. T., Krause, M. O., & Turkstra, L. S. (2008). Dual task training aims to restore executive functions that are often affected by TBI; it is sometimes used to train tasks across both physical and cognitive-communicative domains (Valovich McLeod & Guskiewicz, 2012). Youth with persisting cognitive and communication deficits post-TBI may continue to have problems as they transition to postsecondary education and to vocational and independent living settings (Todis, Glang, Bullis, Ettel, & Hood, 2011). The Journal of Head Trauma Rehabilitation, 23, 394–400. This skill typically develops in early adolescence; it is often deficient in youth with TBI, resulting in academic challenges. Videoconferencing and interactive skills-based programs via telepractice may be more meaningful for providing support and information to caregivers than self-guided web sessions (Rietdijk, Togher, & Power, 2012). Acute characteristics of pediatric dysphagia subsequent to traumatic brain injury: Videofluoroscopic assessment. A compilation of assessment and treatment protocols specifically designed for use in Lack of overt deficits in these very young children just after TBI does not mean that they will not require services later. Damage can result from a primary injury or a secondary injury (see common classifications of TBI for more details). Perspectives on School-Bases Issues, 13, 87–93. According to the National Center for Injury Prevention and Control, an estimated cumulative 5.3 million individuals are living with a TBI-related disability in the United States. American Journal of Speech-Language Pathology, 17, 299–317. Cassaundra N. Miller, MS, CCC/SLP. advocate for their child by providing important information about performance in home and school as the child progresses through transitions. A functional imaging study of translation and language switching. Assessments are sensitive to cultural and linguistic variables. Available 8:30 a.m.–5:00 p.m. (2003). cognitive-linguistic deficits (e.g., auditory processing and memory loss) that can affect learning, recall, and use of compensatory swallowing; neurobehavioral deficits (e.g., impulsivity, agitation); perceptual deficits (e.g., visual field neglect); physical limitations that can affect motor control and posture; and. Training communication partners of people with severe traumatic brain injury improves everyday conversations: A multicenter single blind clinical trial. American Speech-Language-Hearing Association Functional Assessment of Communication Skills for Adults (ASHA FACS). Mild traumatic brain injury in the United States, 1998–2000. Dessy, A. M., Rasouli, J., & Choudhri, T. F. (2015). In developing a treatment plan, clinicians consider age, previous levels of function, and developmental status as well as functioning in related areas, such as sensory and motor skills. A Scoping Review of Interventions for Adults With Dysarthria Following Traumatic Brain Injury Gandhi, P., Tobin, S., et al. Concussion management: The speech-language pathologist's role. The speech-language pathologist's role in vocational outcomes. Epidemiology of concussions among United States high school athletes in 20 sports. Deidrick, K. K., & Farmer, J. E. (2005). Journal of Medical Speech-Language Pathology, 13, x–xxxviii. Depending on the individual's overall alertness and ability to participate, the clinical bedside examination may also include feeding trials of a variety of food textures and liquid consistencies. Family-centered practice can provide a way to improve the family's ability to adapt to changes brought about by the TBI by helping family members communicate openly, identify priorities, and learn how to problem-solve together (Wade, 2006; Wade, Wolfe, Brown, & Pestian, 2005). Ylvisaker, M. E. (1998). Pediatrics, 116, 1374–1382. These approaches are not mutually exclusive; aspects of more than one approach often are integrated into the delivery of services. Intervention may focus on the individual speech subsystems of respiration, phonation, articulation, and velopharyngeal function or, more globally, on overall verbal communication function using behavioral and instrumental treatments, compensatory strategies, and/or environmental modifications. Deficits in any of the areas noted above can have a negative impact on the success of treatment. Salvatore, A. P., & Fjordback, B. S. (2011). (1998). Strategic learning in youth with traumatic brain injury: Evidence for stall in higher-order cognition. Ylvisaker, M. E., Turkstra, L., & Coelho, C. (2005). Morgan, A., Ward, E., & Murdoch, B. Findings from the speech-language and audiology assessments are considered in the context of findings from other professionals on the team. Longitudinal investigation of the post-high school transition experiences of adolescents with traumatic brain injury. Review case history information, including medical information and emotional and mental status, Review previous assessments (e.g., speech-language, physical therapy, occupational therapy, audiologic), Gather additional details related to hearing, balance, and auditory processing difficulties, Pure-tone and speech audiometry, including modifications (as needed) such as, Otoacoustic emissions or auditory brainstem response testing—if accurate test results cannot be obtained using traditional behavioral testing methods, Semicircular canal function tests, such as caloric, rotational, and video head impulse testing, Otolith testing, such as (a) ocular and cervical vestibular-evoked myogenic potential (VEMP) and (b) the subjective visual vertical (SVV) test, Neurobehavioral deficits, such as agitation and combativeness, Motor deficits (e.g., postural limitations. Evidence-based review of moderate to severe acquired brain injury: Executive summary. The full extent of deficits may become evident only as the child's brain matures and expected skills fail to develop or emerge more slowly (McKinlay & Anderson, 2013). Penn, C., Frankel, T., Watermeyer, J., & Russell, N. (2010). This type of intervention does not refer to the use of computers or electronic devices (e.g., electronic memory aids or web-based organizational assistants) as external aids. Traumatic brain injury: Associated speech, language, and swallowing disorders. In task analysis, a target skill is analyzed or broken down into a sequence of smaller steps that can be taught one step at a time and then chained together. DoD Standard surveillance case definition for TBI: Adapted for the Armed Forces Health Surveillance Branch (AFHSB). In J. E. Farmer, J. Donders, & S. A. Warschausky (Eds. However, individual states may define TBI more broadly and may include children with nontraumatic acquired brain injury (e.g., stroke, brain tumor, anoxia) when determining eligibility for services. Management can include the use of hearing aids, sound masking, counseling, and cognitive-behavioral interventions. Treatment for hearing loss may include selection and fitting of amplification devices and training in the use of assistive technologies (e.g., frequency modulation [FM] systems in classrooms). See ASHA's Practice Portal Page on Telepractice. Brain Impairment, 8, 276–292. The Individuals with Disabilities Education Improvement Act of 2004 (IDEA) defines TBI as. Therefore, some children may not present with immediate effects of TBI, but will experience challenges later in their development, particularly as academic demands increase (Gerrard-Morris et al., 2010; H. G. Taylor et al., 2008). Metacognitive skills training is an integral part of DAT when used to treat cognitive-communication deficits in children with TBI (e.g., Lee, Harn, Sohlberg, & Wade, 2012; Sohlberg, Harn, MacPherson, & Wade, 2014). For children with mTBI/concussion, treatment typically is centered in school- or community-based settings. Child: Care, Health and Development, 36, 44–53. Management of persistent cognitive symptoms after sport-related concussion. Pediatric traumatic brain injury: Where do we go from here? Habilitative approaches target skills that have not yet developed. Some young children with TBI may demonstrate relatively typical developmental progression after the initial stages of recovery. Doyle, M., & Fager, S. (2011, February). The auditory and vestibular consequences of traumatic brain injury and the role of the audiologist on the interdisciplinary management team (Unpublished capstone project). The full sequelae of pediatric TBI can emerge and/or persist well into adulthood, lending to the perspective that TBI in children is a chronic disease process rather than a one-time event (DePompei, 2010; DePompei & Tyler, in press; Masel & DeWitt, 2010). Sohlberg, M. M., & Ledbetter, A. K. (2016). The impact of new demands and challenges is assessed so that strategies to maximize functional outcomes and life participation can be implemented (Blosser & DePompei, 2003; New Zealand Guidelines Group, 2006). Interventions for children with premorbid deficits in knowledge and skills will differ from interventions for children who have not yet developed certain knowledge or skillsets (Turkstra et al., 2015). Signs and symptoms may co-occur with other existing developmental conditions such as attention-deficit/hyperactivity disorder, learning disabilities, autism spectrum disorder, intellectual disability, childhood apraxia of speech, childhood fluency disorders, late language emergence, spoken language disorders, written language disorders, and social communication disorders. Cognitive function and assistive technology for cognition: A systematic review. A., Zaugg, T. L., & Kendall, C. J. attending to, perceiving, and processing verbal and nonverbal information; remembering verbal and nonverbal information; and. Poster session presented at the annual convention of the American Speech-Language-Hearing Association, Boston, MA. (2004). The roles of speech-language pathologists and audiologists in concussion prevention and management—including baseline testing and "return to learn" protocols—have become more prominent, especially in the school setting (Halstead et al., 2013; Hotz et al., 2014). Perspectives on School-Based Issues, 5, 14–19. Intervention facilitates participation in meaningful activities by involving individuals in a long-term, collaborative project that results in a tangible product. Wild, M. R. (2014). Atlanta, GA: National Center for Injury Prevention and Control. Modifications for students with TBI may include shortened class schedule or day, reduced number or type of assignment, or modified response type (e.g., multiple-choice questions instead of recall questions or short-answer questions). It is important to recognize that these two domains are intrinsically and reciprocally related in development and function. Burns, M. S. (2004). Pediatrics, 132, 948–957. Augmentative and alternative communication (AAC) involves supplementing or replacing natural speech and/or writing with aided (e.g., pictures, line drawings, speech-generating devices, and tangible objects) and/or unaided (e.g., manual signs, gestures, and finger spelling) symbols. The Lancet, 18, 56–87. Different dimensions of culture may influence an individual's views on seeking care and external support following a TBI (see ASHA's resource on examples of cultural dimensions). Timing refers to the timing of intervention relative to the injury. Children who are unable to use natural intelligible speech for communication (e.g., due to severe dysarthria or a voice disorder) may need long-term AAC (Doyle & Fager, 2011). Journal of Rehabilitation Research and Development, 46, 797–810. Therefore, these estimates may significantly underestimate the incidence and prevalence of pediatric TBI. See the Traumatic Brain Injury section of the Pediatric Brain Injury Map Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspectives. Computer-based cognitive rehabilitation for individuals with traumatic brain injury: A systematic review. Prevalence refers to the number of individuals who are living with TBI in a given time period. The following are brief descriptions of both general and specific treatments for persons with cognitive-communication and swallowing disorders associated with TBI. SLPs and audiologists do not diagnose TBI. Kennedy, M. R. T., O'Brien, K. H., & Krause, M. O. Waltham, MA: Butterworth-Heinemann. breaking the targeted task down into small, discrete steps; modeling target behavior before the person attempts each step; immediately correcting errors, modeling the correct step, and asking the person to do it again; and. Team members may include physicians, physical and occupational therapists, teachers, neuropsychologists, and school psychologists. Turkstra, L. S., Quinn-Padron, M., Johnson, J. E., Workinger, M. S., & Antoniotti, N. (2012). Incidence and descriptive epidemiologic features of traumatic brain injury in King County, Washington. PLAY. The Journal of Head Trauma Rehabilitation, 29, 338–352. See ASHA's Practice Portal Page on. (2015). Journal of the Neuropsychological Society, 18, 1–19. Metacognitive skills training—also called metacognitive strategy instruction—focuses on improving awareness, self-monitoring, self-regulation, and use of goal-setting strategies to facilitate learning and behavioral success. It is provided in the language(s) used by the individual with TBI. Whereas age-adjusted rates of TBI-related ED visits increased by 54% over the span of 8 years (2006–2014), hospitalization rates decreased by 8% and death rates decreased by 6% (CDC, 2014). Identification of relevant follow-up services for appropriate intervention and support. Causes of pediatric TBI are varied and appear to differ by age. Bonelli, P., Ritter, P., & Kinsler, E. (2007, November). Sensory stimulation—also referred to as coma stimulation—is the systematic exposure of an individual with severe TBI to a variety of visual, auditory, tactile, olfactory, and kinesthetic stimuli to improve arousal/level of consciousness and prevent sensory deprivation. See ASHA's Practice Portal page on Voice Disorders. Dosage depends on individual factors, including the child's arousal level and ability to tolerate therapy sessions, prognosis, stage in recovery, and frequency of other therapeutic activity (CDC, 2015). Traumatic brain injury in the United States: Emergency department visits, hospitalizations and deaths 2002–2006. American Journal of Sports Medicine, 39, 958–963. Turkstra, L. S., Politis, A. M., & Forsyth, R. (2015). having the metacognitive and executive functioning skills necessary for interacting in home, school, and community settings. Assessment of Language-Related Functional Activities (ALFA) ... on 175 patients with neurogenic communication disorders resulting primarily from left or right hemisphere stroke and traumatic brain injury, and the patient level of care ranged from acute and subacute to home and outpatient settings. Brain, 122,2221–2235. Rehabilitation and ongoing support after pediatric TBI: Twenty years of progress. ), Treating neurodevelopmental disabilities: Clinical research and practice (pp. Non-standardized assessment approaches for individuals with cognitive-communication disorders. The typical developmental trajectory of social and executive functions in late adolescence and early adulthood. Habilitative interventions help children learn, keep, or improve skills and functional abilities following their injury rather than restore skills that they had mastered prior to injury. Fausti, S. A., Wilmington, D. J., Gallun, F. J., Myers, P. J., & Henry, J. Often, aspects of more than one approach are integrated in the delivery of speech and language services. Traumatic brain injury in young children: Post-acute effects on cognitive and school readiness skills.Journal of the International Neuropsychological Society, 14, 734–745. Person- and family-centered care for individuals with TBI. Intervention for dysarthria associated with acquired brain injury in children and adolescents. Students with TBI may require specialized instruction and support, accommodations, and assistive technology to access the educational curriculum and demonstrate knowledge based on their cognitive-communication and academic needs. Speech, language, and/or cognitive deficits that existed prior to the TBI—such as attention-deficit/hyperactivity disorder, autism spectrum disorder, childhood apraxia of speech, acquired apraxia of speech, learning disabilities, speech sound disorders, spoken language disorders and written language disorders—must also be considered. Thurman, D. J., Alverson, C., Browne, D., Dunn, K. A., Guerrero, J., Johnson, R., . (2012). hypersensitivity to sounds (hyperacusis); tinnitus (see ASHA's Practice Portal page on, Changes in perception of color, shape, size, depth, and distance, Problems with visual convergence and accommodation, Tactile—sensitivity or defensiveness to touch; changes in perception of pain, pressure, and/or temperature, Deficits in shifting attention between tasks, Impaired sustained attention for task completion or conversational engagement, Reduced processing speed (e.g., of rapid speech and/or complex language), resulting in confusion, Deficits in short-term memory that negatively affect new learning, Deficits in working memory that negatively affect following directions, Difficulty retrieving information from memory, Lack of insight for monitoring one's strengths, weaknesses, functional abilities, problem situations, and so forth, Reduced awareness of deficits (anosagnosia), Deficits in orientation to self, situation, location, and/or time, Impaired spatial cognition that can affect ability to navigate and ambulate, Difficulty initiating conversation and maintaining topic, Impaired ability to use nonverbal communication effectively (e.g., tone of voice, facial expression, body language), Inability to interpret nonverbal communication of others, Decreased ability to formulate organized discourse or conversation, Difficulty understanding abstract language/concepts, Tendency to perseverate in verbal responses, Use of incoherent or confabulatory speech, Difficulty comprehending written text, particularly with respect to complex syntax and figurative language, Difficulty planning, organizing, writing, and editing written products, Aprosodia/dysposodia, marked by deficits in intonation, pitch, stress, and rate, Dysarthria characterized by articulatory imprecision and/or vowel distortions, Hypernasality secondary to paresis or paralysis of velopharyngeal muscles involved in speech, Aphonia/dysphonia resulting from intubation, tracheostomy, or use of mechanical ventilator, Laryngeal hyper/hypofunction marked by abnormal pitch; poor control of vocal intensity; or changes in vocal quality (e.g., hoarseness, strained–strangled voice, glottal fry), Neurogenic phonatory abnormalities resulting from injury to sensory or motor innervations to the vocal folds, Psychogenic phonatory abnormalities (e.g., related to post-traumatic stress disorder), Risk of aspiration related to impact of cognitive impairment (e.g., poor memory, reduced insight, limited attention, impulsivity, and agitation) while eating, Agitation, aggression, and/or combativeness, Changes in affect—overemotional, over reactive, emotionless (flat affect), Changes in sleep patterns (e.g., insomnia or hypersomnia), Difficulty identifying emotions of self and others (alexithymia), Heightened sensory sensitivity with exaggerated reactions to perceived threats (hypervigilance), Changes in play (e.g., loss of interest in favorite toys/activities), Irritability, persistent crying, and inability to be consoled, Loss of new skills, such as toilet training, Providing prevention information to individuals and groups known to be at risk for TBI as well as to individuals working with those at risk, Screening children with TBI for hearing, speech, language, cognitive-communication, and swallowing difficulties, Determining the need for further and ongoing assessment and/or referral for other services, Conducting a comprehensive assessment and diagnosing speech, language, cognitive-communication, and swallowing disorders associated with TBI, with sensitivity to individual differences, including cultural and linguistic variations, Developing and implementing treatment plans involving direct and indirect intervention methods for maintaining functional speech, language, cognitive-communication, and swallowing abilities at the highest level of independence, with sensitivity to individual, cultural, and linguistic variations, Gathering and reporting treatment outcomes, documenting progress, and determining appropriate discharge criteria, Facilitating the transition of services between medical, educational, community, and vocational settings, Counseling persons with TBI and their families regarding impairments across the SLP scope of practice and providing education aimed at preventing further complications relating to TBI, Providing training (e.g., in the use of augmentative and alternative communication [AAC] systems) to persons with TBI and their families, caregivers, and educators, Serving as an integral member of an interdisciplinary team working with individuals with TBI and their families/caregivers, including participating as a member of the school planning/individualized education program (IEP) team to determine eligibility, appropriate educational services, and transition planning, Consulting and collaborating with other professionals (e.g., teachers, neuropsychologists, occupational and physical therapists) to facilitate program development and to provide supervision, evaluation, and/or expert testimony, as appropriate, Advocating for individuals with TBI and their families, particularly in school settings where cognitive-communication disorders may be mistaken for attitudinal or motivational problems, Educating other professionals, third-party payers, and legislators about the needs of children with TBI and the role of SLPs in diagnosing and managing speech, language, cognitive-communication, and swallowing disorders associated with TBI across settings, Remaining informed of research in the area of TBI and helping advance the knowledge base related to the nature and treatment of cognitive-communication and swallowing deficits associated with TBI, Educating other professionals about the needs of children with hearing and vestibular/balance deficits post-TBI and the role of audiologists in diagnosing and managing them, Identifying hearing and vestibular/balance deficits post-TBI, including early detection and screening program development, management, quality assessment, and service coordination, Conducting a comprehensive and culturally and linguistically sensitive assessment, using behavioral, electroacoustic, and/or electrophysiological methods to assess hearing, auditory function, vestibular and balance function, and related systems, Referring the child with TBI to other professionals as needed to facilitate access to comprehensive services, Evaluating children with hearing and vestibular deficits post-TBI for candidacy for amplification and other sensory devices, assistive technology, and vestibular rehabilitation, Fitting and maintaining amplification and other sensory devices and assistive technology for optimal use, Developing and implementing an audiologic and/or vestibular rehabilitation management plan, Creating documentation, including interpreting data and summarizing findings and recommendations, Counseling the child with TBI and his or her family regarding the psychosocial aspects of hearing loss and other auditory processing dysfunction, modes of communication, and processes to enhance communication competence, Providing communication skills training for families and other professionals who interact with the child, Advocating for the communication needs of all individuals, including advocating for the rights to and funding of services for those with hearing loss, auditory disorders, and/or vestibular disorders, Remaining informed of research in the area of TBI and helping advance the knowledge base related to the nature, identification, and treatment of hearing and vestibular deficits post-TBI, Behavioral factors, such as agitation and combativeness, Decreased physical endurance and ability to participate, Sensory deficits (e.g., visual neglect, hearing loss), Presence of co-existing premorbid conditions such as attention-deficit/hyperactivity disorder, learning disabilities, and developmental disabilities, The impact of communication impairments on.

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