PowerPoint Document - The Post Concussion Syndrome

							  Energy Management & Awareness
 Training in Mild Traumatic Brain Injury
(MTBI) with Post Concussive Syndrome.

 Helen Mathison, M.A. CCC-SLP
  Linda Mabbs, M.A. CCC-SLP
 Allison Carolan, M.S. CCC-SLP
  Janet Malotky, M.A. CCC-SLP
Learning Objectives
1. Historical perspective and current evidence on Post
Concussive Syndrome in MTBI.

2. Importance of Energy Management and Awareness Training
for successful outcomes in MTBI.

3. Benefits of a Interdisciplinary approach in treatment of MTBI
with Post Concussive Syndrome.

4. Issues with Post Concussive Syndrome in return to school
and return to work for persons with MTBI.
 Post-Concussion Syndrome
• Mild TBI account for 75% all TBIs.

• Post-concussion syndrome is a complex disorder in
  which a combination of post-concussion symptoms —
  such as headaches and dizziness — last for weeks and
  sometimes months after the injury that caused the
  concussion.

• In most people, post-concussion syndrome symptoms
  occur within the first seven to 10 days and go away
  within three months, though they can persist for a year or
  more.
   Post-Concussion Syndrome
                       Symptoms Include:
       Headache                         Irritability Memory problems
       Dizziness                        Anxiety      Impaired sustained
       Vertigo                          Depression attention
       Tinnitus                         Personality Increase distractibility
       Hearing loss                                  Slowed processing speed
                                          Smell/taste changes
                                        change
       Blurred vision                                Word retrieval problems
                                          Sleep disturbance
       Diploplia                          Fatigue
       Photophobia                        Phonophobia



Evans et al (1993). The Physician Survey on the Post-Concussion and Whiplash Syndromes. Headache 34: 268-274.
          A Historical Perspective
Physician’s Survey of Post Concussive and Whiplash Syndromes, 1993:

•Mailed a survey
questionnaire to 750 FP,
475 Neurologists, 425
Neurosurgeons, and 625
Orthopedists.
•Physicians did not feel
that Post Concussive
Symptoms made up a
“well-defined
syndrome.”
            A Historical Perspective
 Physician’s Survey of Post Concussive and Whiplash Syndromes, 1993:

• Reasons for this skepticism:
   – Chronic post concussive
     symptoms were not
     predicted by injury
     “severity.”
   – Chronic post concussive
     symptoms did not appear
     to develop or resolve in
     any particular order.
   – A somewhat
     disproportionate number
     of patients were involved
     in litigation related to
     injury.
   – It must be psychological
     vs. neurologically organic.
          A Historical Perspective
Physician’s Survey of Post Concussive and Whiplash Syndromes, 1993:


    “Even though
      they have
   symptoms, the
     sooner they
 ignore them and
 get on with their
  lives, the faster
       they will
   improve.” --NS
            A Historical Perspective
Physician’s Survey of Post Concussive and Whiplash Syndromes, 1993:

 However… Physicians were
beginning to recognize a that “A
growing body of evidence supports
the organicity of PCS.”

 Definition of mild TBI in 1993:
“Any alteration in mental state at
the time of the accident (feeling
dazed, disoriented, or confused).”

 Assessments were still not
sensitive to TBI and majority of
physicians continued to assess
with clinical neurological
examination and CT scans.
          A Historical Perspective
Physician’s Survey of Post Concussive and Whiplash Syndromes, 1993:


  “Litigation and
  compensation
    are the main
       issues.
      Emotional
 instability— lack
       of goal
  orientation and
 direction in one’s
   life are major
   factors.” --FP
―Syndrome‖ Semantics

           “Indicators of a syndrome
           include consistent
           symptom linkage and
           coupling of symptom
           response to treatment.
           Consistency of clinical
           presentation is not readily
           supported by the current
           clinical studies of this
           population.”
       ―Syndrome‖ Semantics
                  TWO CAMPS:

1)―Post Concussive Syndrome a neurobiological
  and pathogenic process specific to TBI.




2)Post Concussive Syndrome is not a true
  syndrome, but is a myriad of co-occurring
  symptoms seen commonly after brain injury, each
  initiated by the same event (TBI) but produced by
  different underlying mechanisms.
Does it REALLY matter??
                       Pathophysiology
                         of Mild TBI:


• Oppenheimer found evidence of axonal injury in
  5 patients with minor or trivial injuries, using
  immunostaining for amyloid precursor protein as
  a marker for axonal injury.

• Blumberg et. al. found multifocal axonal injury in
  five individuals who had sustained very mild
  injuries with brief periods of unconsciousness.
                          Pathophysiology
                            of Mild TBI:

• Animal Models: cats (fluid percussion) and primates
  (angular acceleration devices) suggest that mild TBI is
  associated with axonal injury.

• Although axotomy occurs at the time of injury, delayed
  axotomy also contributes to the outcomes. The process
  involves initial changes to the permeability of the
  axelomma (axonal membrane), which leads to secondary
  deafferentiation.
         Imaging Studies in MTBI
• Newer imaging techniques such as
  PET, SPECT, fMRI, MRS,and pre-
  pulse MRI show promise in detecting
  subtle sequelae of MTBI.

• See also Electrophysiological
  measures such as EEG, QEEG, EP,
  ERP.

• Better imaging validates cognitive
  testing.
                               Secondary Gain
    “There is compensation claims and
 Patients with a longstanding, and
   probably compared with those w/o
  litigation asill-founded, view that
                     have:
      because MTBI is uniformly
         Similar symptoms improving with time
                with cognitive recovery,
  associated Similar a goodtests
individuals with a poor outcome are
          Similar response rates to Tx of HA
                Similar recovery rates
   tobe considered abnormal and
       The majority of plaintiffs who have persistent
   regarded with some suspicion.”
        symptoms are not cured by the verdict.
     Evans et al (1993). The Physician Survey on the Post-Concussion and Whiplash
                            Syndromes. Headache 34: 268-274.
  McAllister & Arciniegas (2002). Evaluation and treatment of postconcussive symptoms.
                                   NeuroRehabilitation 17 (265-283).
ASHA SCOPE OF PRACTICE
Language and
Cognition
 Attention
 Memory
 Sequencing
 Problem solving
 Executive functioning

Clinical Services
 Prevention and pre-referral
 Screening
 Assessment/evaluation
 Consultation
 Diagnosis
 Treatment, intervention, management
 Counseling
 Collaboration
 Documentation
 Referral
    Why Energy Management?
• The Brain is the only organ
  in the body that requires
  sleep

• Although the brain
  represents only 2% of the
  body weight, it receives
  15% of the cardiac output,
  20% of total body oxygen
  consumption, and 25% of
  total body glucose
  utilization.
          The Coping Hypothesis
• Fatigue is present in up to 70% of mTBI patients.
• Fatigue can be related to mental effort necessary to
  overcome attention deficit and slowed processing
  (―coping hypothesis‖).
• Fatigue can also be related to endocrine or metabolic
  disturbances in the brain following MTBI
• ―TBI individuals expend greater psychophysiological
  costs in order to maintain stable performance over
  time, and that these costs are associated with
  subjective increases in fatigue.

Bushnik et. al. (2007)
Ziino & Ponsford (2006)
 Evidence for Energy Management
    Existing studies generally have involved individualized
 counseling, providing information about expected symptoms
          Treatments need to focus on
  and suggested coping strategies, and in some cases regular
                            follow up.
   correcting the underlying cause of the
    sleep problem been to address patients’
Positive outcomes haveand found by
1) Relander et al. Controlled Trial for Treatment of Concusson,
    subjective experiences of their sleep,
   BMJ 1972; 4: 777-779.
    through individualized TBI education,
2) Miinderhoud et. al. Treatment of minor head injuries Clin
    teaching coping and compensation, and
   Neurol Neurosurg 1980; 82: 127-140.
    mood al. Routine follow up after head injury: a second
3) Wade et.stabilization.
   randomized controlled trial. J Neurol Neurosurg Psychiatry.
   1998; 65 177-183.
Evidence for Energy Management
•   Fatigue, depression, pain, and organic sleep problems are
    much more prominent in individuals with TBI than in
    controls. Cause of fatigue following TBI is not only organic
    (pushing through pain and PCS with de-compensation
    exacerbates organic fatigue)
•   Post TBI fatigue is correlated with health-related quality of
    life and overall quality of life, but in studies, it is not always
    related to participation in major life activities (Because rest
    is not intuitive).
•   Post traumatic brain injury fatigue cannot be accounted for
    by co-morbid variables such as depression, etc.
                           Baumann et. al. (2007).
                            Bushnik et. al. (2007)
                            Cantor et. al. (2008)
 Evidence for Energy Management
  Why do SLPs need to give specialized awareness training
                         to mTBI patients?
•   Pts may not acknowledge, or may minimize, the severity of
    acquired deficits for up to several years following mTBI.
•   Patients don’t realize functional deficits before they return to
    full function; need awareness in effective early intervention.
•   Pts require “rest” education because it is not intuitive for
    them in the initial month they are out of work. As Kent points
    out, ―the deeper and more comprehensive an individual’s
    awareness becomes, the more the person is able to apply
    their understanding to new and different situations.”
•   ―There is a high prevalence of sleep disorders (46%) and of
    excessive daytime sleepiness (25%) in subjects with TBI.‖
    Sleepy subjects may be more cognitively impaired than
    comparable non-sleepy subjects with TBI, yet be unaware of
    problems.‖          Flashman L & T McAllister, 2002
                             Kent 1999 JHTR
                           Castriotta et. al. 2007
    Evidence for Energy Management
•    Compared with controls, TBI patients reported
     significantly poorer sleep quality. Objective
     sleep recording showed that TBI patients
     showed an increase in deep (slow wave)
     sleep, a reduction in rapid eye movement
     sleep and more frequent night time wakings.

•    Injury severity is not predictive of sleep
     impairment.

•    Findings contribute to a growing body of
     evidence that sleep is involved in the
     physiologic processes underlying neural
     recovery.‖ In order to ensure maximal
     cognitive recovery (in addition to teaching
     compensation techniques), fatigue should be
     closely managed by rehab team.
                                                     Parcell et. al. (2008)
Evidence for Energy Management
    What are the most common PCS symptoms
    that SLPs indirectly treat through energy
    conservation education and awareness
    training?
•   Poor memory, sleep disturbance, and fatigue are
    among the most commonly reported symptoms
    (fatigue and memory compensation are strongly
    correlated).
•   Findings in studies suggest a relationship
    between subjective fatigue (mental fatigue) and
    impairment on tasks requiring higher order
    attentional processes (e.g. auditory working
    memory).
                     Lundin et. al. (2006)
                  Siino C & Ponsford J (2006)
                 Summary
• Injury severity does not predict severity or
  presence of PCS.
• PCS create the need to cope or decompensate,
  which expends mental and physical energy.
• To add insult to injury, majority of Pts with TBI
  experience sleep disturbance.
• Energy management and awareness training
  have been shown to be effective in managing
  post concussive symptoms, and subsequently,
  improving cognition.
 Overview of Speech Language
       Pathology’s Role

• Assessment of cognitive-linguistic abilities
• Intervention
   – Direct treatment of cognitive-linguistic impairments
   – Compensation training of cognitive-linguistic
     impairments
   – TBI Education
   – Energy Management training
   – Guidance about return to work/school
Compared with before the accident, do you now
                        Assessment
(i.e., over the last 24 hours) suffer from:
Headaches.................................................... 0 1 2 3 4
Feelings of Dizziness ................................. 0 1 2 3 4
Nausea and/or Vomiting ............................ 0 1 2 3 4
• In depth interview
Noise Sensitivity,
easily upset by loud noise ......................... 0 1 2 3 4
         -Diagnostic interview
Sleep Disturbance ...................................... 0 1 2 3 4
Fatigue, tiring more easily ......................... 0 1 2 3 4
                                            symptom 3 4
         -Postconcussive...................0 1 2questionnaire
Being Irritable, easily angered
         (RPQ)
Feeling Depressed or Tearful .................... 0 1 2 3 4

• Formal cognitive-linguistic assessment
Feeling Frustrated or Impatient ................. 0 1 2 3 4
Forgetfulness, poor memory ..................... 0 1 2 3 4
Poor Concentration ................................... 0 1 2 3 4
           -Observe ............................. 0 1 2 3 4
Taking Longer to Thinkbehaviors & symptoms
Blurred Vision ............................................ 0 1 2 3 4
           -Observe strategy use
Light Sensitivity,
• Informal evaluation of multi-processing
Easily upset by bright light ...................... 0 1 2 3 4
Double Vision ............................................ 0 1 2 3 4
  abilities
Restlessness ............................................. 0 1 2 3 4
Are you experiencing any other difficulties?
1. _________________________________ 0 1 2 3 4
    Essential Components of Treatment



• Energy management training
• TBI education
• Awareness training
• Cognitive remediation
• Customized goals for daily responsibilities,
  work &/or school
• Regular interdisciplinary communication
                                         Immediately After
Concepts of Energy                       TBI
   Management                            Returning to
                                         Life and Activities
•   Rest & breaks allow brain
    to heal.                              Premorbid
•   Resource allocation—
    Multitasking is not helpful.
•   Overtly train client how to
    scale back (may seem counter intuitive to
    ―getting better‖).
•   Recovery curve and awareness is ―up &
    down‖ & help client to expect it & accept it.
•   The ―energy pie‖ will be smaller than normal
    for some time.
   Energy Management
 Stage One--Scaling back

First: TBI education
- Pathophysiology
-Typical symptoms (related to
     RPQ)
-Definition of rest & rationale
-Resource allocation
-Recovery curve
-Interplay between cognition &
     PCS
-Involve family/friends
      Energy Management
    Stage One--Scaling back
•   Use of energy management form & log
    - Client writes activities & symptoms daily.
    - May find rating scale helpful.
    - Teach & reinforce sleep hygiene.
       (Planning and awareness).
    - Add in hourly rests/breaks (or more).
    - Possibly add in naps.
    - Initially have client focus on observing
       relationship between activities, rest &
       cognition.
      Energy Management
    Stage One--Scaling back
•   Review energy log in detail during initial
    treatment sessions
    -Analyze progress with meds, rest, sleep,
    breaks, microbreaks
    -Look for small, subtle ―nuggets‖ of what
    lessens or exacerbates symptoms

•   Be an active, patient listener
         Energy Management
       Stage One--Scaling back
• Train client to be own detective
  -Interpret symptoms
  -Identify triggers & look for patterns
  -Minimize symptoms with behavior change
• Address awareness
  -Train client to recognize changes before symptoms
  worsen
• Validate symptoms & difficulty scaling back
  -Provide support & help with problem solving
       Awareness Training
• Train client to be own expert.
• Client lists how she thinks she’ll do on a task & what
  strategies she’ll use.
• Complete task.
• Client gives own assessment of performance, change
  in any symptoms & effectiveness of strategies.
• SLP gives assessment, comparison of discrepancies,
  feedback.
• Self awareness often comes through ―failures.‖
       Energy Management
      Stage Two--Stabilization

• Start to plan more specific time & activity
  management once you find patterns
• Further customize rest, breaks, microbreaks
• Continue to limit triggers
• Remove self from tasks/locations earlier (Plan B
  or ―escape routes‖)
• Goal is symptom stability/resolution within this
  current stage
• Note: All of the above concurrently address
  energy conservation and cognition.
 Energy Management
Stage Three--Rebuilding
• Client lists tasks that were taken
  off plate
• Work together to add these back in (modify to
  follow energy conservation)
• Have client describe plan in detail
• Change only one factor at a time when
  incrementally adding in tasks
• May need to add in “recovery” days
• Be stable in symptom control before adding
  more activities
          Adjustment/Acceptance

• Provide continuous TBI education
  to normalize the experience
• Provide support & encouragement
  especially in light of how invisible
  this type of injury is
• Help them accept the
  changes/length of recovery
• Help them adjust to reduced
  quality of life, scaled back activity
  level
     Interdisciplinary Team

• ―All this time I just thought I was
  going crazy.‖

• ―I wish I had known this stuff two
  years ago!‖
   Common patient complaints
• Physical Symptoms: headaches, dizziness,
  sleep disturbance, fatigue, photo- and/or
  phonophobia

• Cognitive changes: forgetfulness, slow thinking,
  word-finding problems

• Mood changes: irritability, frustration,
  depression, anxiety, restlessness
      Patients always need

• Medical or medication management
• TBI education
• Energy management guidance and
  awareness training
• Counseling and support
     Patients frequently need

• Cognitive rehabilitation, including
  compensatory strategies
• Occupational therapy
• Clinical psychological services
• Coordination, liaison, and counseling
  concerning return to work/school
     Patients sometimes need

• Rehabilitation for visual issues (e.g.
  convergence insufficiency or scanning
  disorders)
• Physical therapy, including treatment for
  vestibular issues
• Help with support system management (e.g.
  disability paperwork, financial issues, sharing of
  information)
  The Interdisciplinary
   Treatment Team




    Success of rehabilitation is
   dependent on an integrated,
  collaborative approach due to
interlinked symptom etiology and
        maintenance factors
  Benefits of team rehabilitation

• Simultaneously addresses variety of patient’s
  symptoms and needs
• More efficient coordination of services through
  the course of recovery
• Message reinforcement and repetition
• Diversified, distributed practice for patients,
  increasing likelihood of generalization of skills
  and strategies
• Group problem-solving and support for clinicians
    MTBI Clinic Team
•   Physical Medicine and Rehab Physician
•   OP Clinical Coordinator/ RN
•   Neuropsychologist
•   Speech-Language Pathologist
•   Audiologist
•   Physical Therapist
•   Occupational Therapist
•   Clinical Psychologist
•   Social Worker
•   Recreational Therapist
•   Advanced Nurse Practitioner
•   Multi-service Coordinator (scheduling)
     Allied Team Members

• Family/social support
• Other medical providers including: primary
  care physician, neuro-ophthalmologist, pain
  clinic
• Employer
• School teacher/counselor, 504 plan
  coordinator and/or disability services office
• Community and agency support people:
  vocational counselor, ILS worker, parole
  officer, case manager
• In-house vocational counselor
• Additional support with system
  navigation and case management
• Time
• What if interdisciplinary team treatment is
  not available?

  – Develop a network for appropriate referrals
       Indications for referral
• To Neuro-ophthalmology 


  – Complaints about vision
  – Blurred or double vision with fatigue
  – Recurrent/persistent headaches, especially when
    reading, watching TV, working on a computer, or
    doing other close work
  – Slow performance or difficulty reading or doing other
    paper-based tasks
  – Errors or slow performance on scanning tasks
  – Complaints or new concerns about driving
  – ―Dizziness‖
     Indications for Referral
• For Vestibular Testing
   – Complaints of dizziness
   – Unsteadiness on feet
   – Nausea
             Indications for referral
• To clinical psychology
   – Signs of difficulty adjusting to changes
   – Premorbid psychosocial history
   – Depression
   – Anxiety
   – Symptoms of PTSD
   – Relationship Issues related to TBI
   – Irritability or quickness to anger
         A word about
overlap/duplication of services

• Areas of potential overlap with SLP role:
  – Occupational therapy (external memory
    aids, cognitive testing, cognitive treatment,
    and functional compensatory strategies for
    cognitive issues)
  – Clinical psychology (supportive counseling)
  – Neuropsychology (cognitive testing)
  – All (energy management)
         A word about
overlap/duplication of services
• Recall the benefits
   – Message reinforcement
   – Diversified, distributed practice of skills and
     techniques
• Take care to
   – Make scope of practice distinctions in
     documentation and goal setting (e.g. OT talks
     about planners in terms of ADLs; SLP talks
     about planners in terms of cognitive
     processes)
            Summary
 Rationale and Method of Energy
Conservation and Awareness Training

Roles of the Interdisciplinary Team

    Ultimate Goals/ Outcomes:
          Return to Life
Issues with Return to School and
        Return to Work


    Mild to Moderate Brain Injury
         Goals of Treatment
• Individualize to patient need
• Maximize cognitive recovery through:
  – Energy conservation/management
  – Awareness training
  – Direct intervention in deficit areas
  – Compensation training
  – Accommodation
            Age-Specific Goals
• Adolescents                     • Adults
   – Ages 13 -18                     – Ages 18(+)
   – Functional return to daily      – Functional return to daily
     living activities                 living activities
                                     – Return to college as
   – Return to school as soon          soon as appropriate
     as possible
                                     – Return to work when
       • Peer groups                   cognitively, physically
       • Academics                     and emotionally ready
                                         • Previous employment
                                         • New employment
                                             – Job training
                                             – Vocational
                                               rehabilitation
Approach Across Populations
• In-depth interview
• Formal cognitive-linguistic assessment
• Determine areas of concern
  – Cognitive
  – Physical
  – Emotional
• Education
• Appropriate referrals
• Therapeutic intervention
           SLP Role Specific to
          Adolescent Population
• Determine appropriate school accommodations with child,
  family and physician input
• Communication with school
   – Social worker
   – SLP
• Therapeutic intervention
   – Energy conservation
   – Awareness training
   – Direct treatment
   – Compensation
   – Study skills
       • High-lighting
       • Note-taking
       • Out-lining
       • Test prep/ taking
     Challenges with Adolescent
            Populations
• Pre-morbid Functioning
    – Behavioral (psychological, emotional)
    – Academic (learning disabilities, ADHD, grades,
      motivation)
•   Developmental Stage
•   Family Support
•   Sports/Extra-curricular Activities
•   Minimizing of Symptoms/Deficits (student/family)
•   Importance of ―fitting in‖ with peers
Return to School Accommodations
          (504 Plan/IEP)
 Cognitive                    PCS
    •   Attention                •   Headache
    •   Memory                   •   Fatigue
    •   Organization             •   Sleep Disturbance
    •   Processing Speed         •   Light Sensitivity
    •   Expressive Language      •   Noise Sensitivity
    •   Receptive Language       •   Mood Changes
                                 •   Other




                              Medications
                                 • Impact on Cognition
                                 • Side Effects
                                 • Administration
               Accommodations
• Attention                         • Memory/Learning
   –   Preferential seating           – Compensation strategies
   –   Tests in quiet environment     – Access to teacher notes
   –   Longer time for tests          – Tape-recording
   –   Increased structure            – Buddy system
   –   Need for re-directions         – Increased routine
                                      – Assignments in writing
                                      – Excused from make-up
                                        work
                                      – Tutoring in specific classes
            Accommodations
• Processing Speed             • Physical (PCS)
   – Extra time for               – Shorter days initially
     assignments
                                  – Frequent breaks
   – Reduced load/homework
                                  – Rest in nurse’s office
   – Repetition
                                  – Open hours/study halls
   – Teacher notes
                                  – Leave class 5 minutes early
• Visual                       • Other
   – Preferred seating            – Drop some classes/summer
   – Take-home or oral tests        school
   – Help with reading            – Specified contact person in
      • increased print             school
      • tutoring                  – No gym/music classes
      • books on tape             – No contact sports without
                                    physician approval
                                      • Define, Educate, Risks
SLP Role with Adult Populations
Therapeutic Intervention
  – Energy Conservation
  – Awareness Training
  – Direct treatment
  – Compensation
  – Maximize readiness to RTW
• Determine need for RTW accommodations
  with the patient and physician
• Communication with employers for RTW
  plan/education
 Challenges with Adult Populations
• Difficulty following energy management due to life demands
  and stressors
• Pre-morbid personality types
   – ―Sleep is a waste of time!‖
   – ―Sleep is my favorite thing to do.‖
• Loss of income
• Current economic times
• Variability in employer support
• Returning to work too soon
• Exacerbation of symptoms with return to work
• Pre-existing psycho-social issues
   – Depression, anxiety, drug and alcohol use, personality
      disorders
• Social and family support systems
Return to Work Accommodations
• Based on Areas of Concern/Deficits:
  – Reduced hours/graduated return to work
     • 4 hours/day (2 weeks); 6 hours/day (2 weeks); 8
       hours/day
  – Reduced responsibilities/work load
  – Frequent scheduled breaks
     • 5 minutes every hour; 30-60 minutes at mid-point
       of shift)
  – Extra time to complete projects initially
  – ‖Buddy system‖ with co-worker
Return to Work Accommodations
  – Checks and balances
     • Double checking work
     • Ongoing two-way feedback
  – Work restrictions (e.g., can’t do previous job)
  – Increase repetition
  – Receive things in writing
  – Manipulation of environment (light, noise,
    distractions, etc)
  – Use of appropriate compensation techniques
    (writing, paraphrasing, confirmation)
Communication with Employers

• Physician letter of accommodation
• Employer/Team conferences
   – Phone
   – In-person
• Brain Injury
  educational materials
SLP Role with College-Age Populations
Determine appropriate accommodations
• Communication with College Disabilities Center
• Therapeutic intervention
   – Energy conservation
   – Awareness training
   – Direct treatment
   – Compensation
   – High level study skills
      • Specific to individual classes
      • Using actual class materials (texts, study guides. Note-
        cards…)
      • Encouraging additional techniques
         Challenges with College-Age
                 Populations
• College Lifestyles
  –   living situations (dorms, apartments)
  –   schedules (lack of routine, long classes, labs)
  –   social life (late nights, alcohol/drugs, parties)
  –   lack of understanding by peers
• Difficulty following through with energy conservation
  and compensation strategies
  – can’t use previous study style
    (procrastination, cramming)
  – poor sleep hygiene
  – difficulty adapting to different
    teaching styles
      Challenges with College-Age
              Populations
• Resistance to change
   – wants to be ―normal‖ again (outward appearance
     may not betray struggles)
   – does not want to change their academic and
     professional goals/plans
   – may need to work for financial aid/scholarships,
     etc.
   – does not take advantage of services (disabilities
     center, counselors, accommodations…)
• Pre-morbid functioning
   – Psychosocial
   – Academic
• Time Management/Organization
Return to College Accommodations
• Reduced credit hours     • Digital recorders, digital
• Strategic planning of      pens, laptops in
  schedule                   classroom
• Staggered tests/finals   • Buddy system
  week                     • Tutoring
• Tests in quiet           • Compensation strategies
  environment              • Physician letter of
• Longer time for tests      medical necessity (allow
• Staggered                  to reduce credits/work
  assignments                without jeopardizing
• Access to teacher          scholarships, insurance,
  notes                      financial aid…)
    College Age Populations:
         Self Advocacy
– Can’t always rely on disabilities center
– Medical team cannot initiate enrollment,
  the student must do this.
– Take advantage of accommodations
– Asking for help
In a perfect world…
          Thank You!
Questions/ Comments/ Discussion