1

Accomplishing More Together: Collaborative Approaches for Treating Social Communication After

Acquired Brain Injury

Heidi Iwashita, M.S., CCC-SLP

McKay Moore Sohlberg, Ph.D., CCC-SLP

OSHA Fall Conference

October 13, 2018

Disclosures

Heidi Iwashita, M.S., CCC-SLP:• No relevant financial or nonfinancial disclosures related to this talk

• Employed as a Graduate Employee for the Communication Disorders & Sciences (CDS) program at the University of Oregon (UO)

• In the doctoral program of CDS at UO

McKay Moore Sohlberg, Ph.D., CCC-SLP:• No relevant financial or nonfinancial disclosures related to this talk

• A salaried professor in CDS at UO

• Receives grant support from the National Science Foundation and National Institute for Health for projects unrelated to this talk

• Receives book royalties for texts unrelated to the content of this talk

Learning Objectives

After completion of this program, you should be able to:

1. Describe three evidence-based collaborative approaches for treating social communication following acquired brain injury

2. Discuss ways to overcome common obstacles to incorporating collaborative treatment approaches

3. Identify communication partner strategies that foster collaborative communication with a person who has had acquired brain injury

Icebreaker

What is your name?

Where do you work?

What kinds of challenges have you experienced collaborating with clients and others?

What are you hoping to learn from this presentation?

OSHA 2018Strength in Collaboration

• Collaboration– Cooperation– Working together on shared goals– Mutual engagement– Repair of breakdowns

• Complex cognitive and communication skills– May be affected by brain injury

• Reduced processing speed• Reduced ability to repair• Difficulty comprehending complex info• Reduced verbal organization or fluency

(Abreu, Zhang, Seale, Primeau, & Jones, 2002)

Aims of Collaborative Approaches

• Maximize engagement

• Honor autonomy

• Resist the “righting reflex”

• Recognize individual and cultural differences

• Create “buy-in”, leading to

• Greater motivation

• Better outcomes

• Harness strengths of family, peers, others to help recovery

• Create a supportive environment

• Promote open communication

2

• People with ABI may be vulnerable to exclusion

– Interdisciplinary meetings

– Treatment decision making

“At times, it was felt that the professionals were the experts in the client’s life, not the client an expert in his or her own life.”

• When included, may not fully participate

– “OK”, “yes,” “no”

– Minimally engaged, passive

“The role of such clients in supposedly client-centered interdisciplinary meetings is therefore like a ‘ritual ghost’ rather than a full participant” (Abreu, Zhang, Seale, Primeau, & Jones, 2002).

“Ritual Ghosts”

What is social communication?

Social

Interaction

• Culture• Gender• Social

reasoning• Social

tasks• Conflict

resolution• Power

relation-ships

Pragmatics

• Theory of Mind

• Emotional competence

• Joint attention

• Inference• Presup-

position

• Verbal:

– Speech acts

– Prosody

– Discourse

• Nonverbal:

– Body language

– Gesture

– Facial expression

– Proxemics

– Gaze shifts

• Comprehension

• Expression

• Morphology

• Semantics

• Syntax

• Phonological skills

Social Cognition

Language Processing

Source: ASHA.org, Components of Social Communication

Assessment of Social Communication

• Numerous tools have been developed

• No perfect tool measures all aspects

• Should look at communication in natural contexts

• Need to consider

– Culture

– Individual and family preferences, priorities

• Often there is a subjective element

– Can you get alternative perspectives?

– Look at functioning in community, with friends, and with everyday communication partners

Assessment Tool Categories & Examples

Performance-based measures

Receptive

Social cognition, e.g. TASIT

Expressive

e.g. FAVRES

Clinician-reported measures

Pragmatic Rating Scales

PRS (see handout)

Adapted Kagan Scales (Togher et al., 2010)

Self/Other reported measures

La Trobe Communication Questionnaire

Common impairments after ABI

• Losing train of thought – memory and attention• Spoken discourse

– Less coherent and informative– More effortful or disorganized

• Has social knowledge, but has difficulty applying it– Self-regulation– Self-awareness

• Emotion perception– Voice– Facial expression, body language

• Emotion expression• Impulsivity• Reduced initiation

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Profile 1: “Denise”

• Dorsolateral/dorsomesial prefrontal lesions

• Reduced initiation

• Apathy

• Lack of drive

• Lethargy

• Inattentiveness

• Reduced spontaneity

• Reduced emotional reactivity

Profile 2: “Eric”

• Orbitofrontal damage due to MVA

• Lack of inhibition

• Impulsiveness

• Lability

• Reduced anger control

• Aggressiveness

• Poor social judgement

Person-Centered Goalsetting

Audience Poll

When working with adults with ABI, how often does the client themselves bring up and decide on the goal(s) they most want to work on with you?

1) It’s the client’s choice 90-100% of the time

2) It’s the client’s choice 70-89% of the time

3) It’s the client’s choice over half but less than 70%

3) I choose goals for my clients more than half the time

4) I choose goals for my clients over 70% of the time

Collaborative Goalsetting

A key part of assessment:– Get client input

• Current functional challenges• Priorities• Readiness to change• Individual/cultural factors

– Set up a meaningful way to measure progress

As treatment:• Direct the client’s attention and effort towards a

specific functional outcome (Berquist et al., 2012)• Increases satisfaction, enhances outcomes (Plant et

al., 2016)

Motivational Interviewing

• Combines interviewing and counseling techniques

• Honors client autonomy

• Increases readiness to change

• Increases motivation

• Strengthens rapport

• Facilitates selection of goals that have larger impact for the client

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Five Principles of Motivational Interviewing

1. Express empathy through reflective listening

-OARS

2. Develop discrepancy between clients' values and current behavior

-Develop awareness

-Arguments for change come from the client

3. Avoid argument and direct confrontation

4. Adjust to client resistance rather than opposing it directly

5. Support self-efficacy and optimismMiller & Rollnick, 1991; Medley & Powell, 2010

Goal Attainment Scaling (GAS)

• Individualized, objective outcome measure based on client-

centered goals

• Criterion-referenced

• Uses a 5-point scale

• Values range from 2 (most favorable) to -2 (least favorable)

• Can obtain standardized scores such as T-scores to analyze

results across clients

Example of GASLevel of Outcome Statement of Outcome

Best outcome Denise initiates social contact 4+times per week

Better than expectedlevel

Denise initiates social contact 3times per week

Expected level afterworking on it for 2-3months

Denise initiates social contact 2times per week

Baseline level Denise initiates social contactonce per week

Goal Attainment Scaling (GAS)

Key Components: SMARTED

• Specific

• Measurable

• Attainable

• Relevant

• Time-specific

• Equidistant

• uniDimensional

Obstacles to Collaborative Goalsetting

Four themes emerged as barriers to goal-setting (Plant et al., 2016):

1. Mismatch between staff and patients’ perspectives

2. Patient-related barriers

• Communication difficulties, cognitive impairments, fatigue, mood disorders, medical co-morbidities, uncertainty, limited awareness

3. Staff related barriers

4. Organizational/service level barriers

• Time, resources

Overcoming Barrier #1: Mismatchin Perspectives

• Open, early, and frequent communication with patients/families about goals

• Explicit strategies to educate patients/families about goalsetting and enhance participation

• Tailor the process to the individual

– Big goals or small?

– Fewer goals

– Patient-led or therapist-led

• Material to support patients in identifying goals

– Example goals

– Worksheets(Plant et al., 2016)

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Overcoming Barrier #2: Patient-Related Barriers

• Cognitive-communication barriers

– Provide written materials in simple language

– Pictures/copies of the goals

– Patient-held records, action plans

• Fatigue

– Timing, breaks

• Mood disorders – team approach

• Family involvement may be facilitative or disruptive

• Uncertainty about recovery process

– Clarify expectations, provide education

Barriers to Goal-Setting: Limited Awareness

• “I don’t have a problem”

– Confrontation can make denial stronger

• Align yourself with them, not against them

• Be positive and encouraging

• Allow them opportunities to experience difficulty

• Education on effects of brain injury

• Structured feedback

Self-directed reflection and feedbackVideo feedback

Journal of successes and struggles

Overcoming Barriers #3 and #4

• Staff-related obstacles

– Education, training

• Organizational/service level barriers

– Time• Limited time for evaluation

• Treatment– Individualized, functional goalsetting as a treatment approach

– Periodic revisiting of goals

– Reviewing progress

– Resources• Interdisciplinary team

Facilitators to Goal-Setting

• Individualized goal-setting process

• Strategies to promote communication and understanding

– Visual aids, written materials, active listening

• Avoiding disappointment and unrealistic goals

– Education on realistic goalsetting

• Staff and patients’ knowledge, experience and enthusiasm for goal-setting

(Plant et al., 2016)

Goal-Setting Worksheets

• Provide simple explanation of goals & measurement

• Space to jot down concerns

• Have clients prioritize and discuss

• Ask the client “how would it make sense to measure that goal?” giving examples

– Times per week

– Duration

– Accuracy

– Rating scales

• Frequently confirm understanding, whether this goal gets at what they want to improve

Useful questions for collaborative goalsetting

• If you could wave a magic wand and change one thing—what would it be?

• How motivated are you to change this? (rate 1-10)

• What have you tried so far?

• What seems to help or not help?

• How would it look for you if this problem completely went away? (GAS +2 level)

• How much do you expect it to get better after working on it for a few months? (GAS 0 level)

• Is there anything else I didn’t ask about?

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Role-Play Demonstration

Self-Reflection & Discussion

• Was this helpful?

• What would you need in order to be committed to

consistently using person-centered goal setting?

Communication Partner Training

Audience Poll

How many of you routinely train the communication partners of a person with ABI to communicate with them more effectively?

What might a communication partner do that hinders the communication effectiveness of a person with ABI?

Communication Partner Training

• Impairment participation• Communication

– Context-bound– Interactive

• Everyday Conversation partners (ECP) may unwittingly sabotage communication

• Post-injury changes by ECP in communication style may give people with ABI fewer chances to shine

• ECP can be taught to – Reveal competence of person with ABI– Provide cognitive and emotional support– Provide facilitative contexts

Communication Partner Training

• More effective than when the person with ABI is trained alone (Togher, McDonald, Tate, Power, & Rietdijk, 2013)

• When given a powerful information-giving role, e.g. a guest speaker, the communication of people with ABI approximated matched control participants (Togheret al., 2011).

• Question your assumptions

– Look at context, interaction

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How Communication Partners maySabotage Communication

• Asking questions they already know the answer to

• Talking down to people with ABI

• Talking too slowly

• Repeatedly checking on accuracy

• Not giving enough opportunities

• Not providing natural consequences

• Failing to follow up on information given by person with ABI

(Togher et al., 2011)

Key Features of Collaboration During Conversation (Ylvisaker et al., 1998; Togher et al., 2011)

• Collaborative intent

“We’re doing this together”

• Cognitive support

“What can help make this easier?”

• Emotional support

“I’m with you, it’s OK”

• Positive question style

“I’m interested in what you have to say”

• Collaborative turn taking

“I’m interested in sharing conversation”

Cognitive Support:Examples

Cognitive Support

• Gives information

• Uses memory aids

• Uses organization supports

• Gives cues

• Gives correct information in a non-punitive manner when correcting errors

Lack of Cognitive Support

• “Quizzes” person with ABI

• Fails to encourage cognitive supports

• No cues

• Corrects in a punishing manner

Togher et al., 2011

Communication Partner Strategy:

Elaboration of Topics

Elaboration of Topics• Topic of interest that can go

further

• Maintain the topic

• Partner contributes information

• Partner asks open-ended questions

Non-Elaborative

• Low-interest topic

• Low potential to elaborate

• Changes topic frequently

• Partner does not add enough information

• Partner does not ask questions

Togher et al., 2011

Communication Partner Strategy:Elaborative Organization(Togher et al., 2011)

Elaborative Organization

• Sequential order

• Causality

• Make connections

• Review organization of information

Non-Elaborative

• Fail to organize information

• Fail to review information

• Fail to make connections clear when topics change

Togher et al., 2011

How to Teach These Strategies

• Group Approach• E.g. TBI Express• Peer support and modeling

• Individualized, family-centered training• Get a baseline with each family member

• Adapted Kagan Scales

• Encourage expression by person with ABI• What’s working, what’s not working• Discuss videos taken outside therapy• Choose one skill to work on at a time• Model skill• Provide frequent opportunities to practice• Family member and person with ABI must demonstrate it

successfully

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Negotiating Group Rules

Partner Training - Obstacles

1. Difficult family adjustment to injury

➢ Hard to reconcile past vs. presentStill coping with “loss” of valued traits in past loved one

➢ Unrealistic expectations for recoveryMay embrace fad diets, pseudoscience

May try hard to “train” the loved one’s memory

2. No partner available

3. Provider level: SLP not aware of need/materials

4. Organizational/service level barriers

• Time, resources

How to Overcome Obstacles

1. Difficult family adjustment

• Listen & validate differences in perspectives

• Be sensitive to cultural and generational influences

• Promote awareness

• Video reflections

• Journals of successes/failures

• Structured self-rating of their own communication

2. No partner available for intensive program

• Train staff

• Make handouts

• Utilize any brief training opportunities

How to Overcome Obstacles

3. Provider level: SLP not aware of need/materials

• Question assumptions, look at context

• Be flexible, take client’s perspective

• Some videos here: http://sydney.edu.au/health-sciences/tbi-express/

• See References list

4. Organizational/service level barriers

• Time, resources• Group therapy?

• Offer training to community brain injury groups

Context-Sensitive Intervention

Context-Sensitive Intervention

• Away from treating individuals in isolation• Situated in everyday activities• Focus on complex interactions• “Everyday, positive routines”

• Ylivisaker & Feeney, 1998• Involves family, staff, peers • Create successful routines in context

• Collaboration• Coaching• Scaffolding

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Principles of Ylvisaker’s (2006) “Self-Coaching” Intervention

Automatic self-regulation

Participant Involvement

Specificity of real-world needs

Negotiation of scripts and metaphors

Motivating associations

Self-coaching plays/scripts and communication partner scripts

Practice Monitoring, revisions, and

celebration

Customized Strategies & Scripts

• Self-coaching scripts

– Individualized

– Address obstacles common after ABI

• Emotion control

• Impulsivity

• Difficulty interpreting others’ behavior

• Trouble managing everyday routines

• Metacognitive Strategies

– Developing awareness

– Learning and practicing when to use

Example Self-Regulatory Scripts(Ylvisaker, 2006)

• “Let’s think about that” (impulsivity)

• “What about you?” (egocentrism)

• Respect (boundaries)

– “Is it OK to give this person a hug?”

– “Does that person like that nickname?”

• “Hang in there” - motivating self-talk

• “Am I ready?”

• “Am I sure?”

Positive Metaphors

Individualized

• Sports: self-coaching

• Music: Self-conducting

• Dance: Self-choreographing

• Business: Self-managing; self-supervising

• Film: Self-directing

• Ranching: Self-shepherding

• Hiking: Self-guiding

• Military: Self-commanding

Positive Metaphors

Choosing a personalized positive role model

– The type of person they CAN be

– when effectively self-regulated• Sports, entertainment

• E.g. Clint Eastwood, Wayne Gretsky

Similarly, the person with ABI can choose an example of a negative role model representing how they are when not effectively self-coached

• A “Mike Tyson” kind of person

Ylvisaker, 2006

Obstacles to Context-Sensitive Interventions

• Lack of self awareness– Denial– Overestimating own ability– Rigid thinking– Pessimism

• Passive attitude– Low initiation– Prefers therapist to lead

• Memory deficits– Remembering when to use

strategies

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Obstacle #1Lack of Self-Awareness

• Inconsistent awareness across domains• Awareness is not unitary

– “Blind spots”– More awareness for motor and sensory deficits than for

cognitive deficits– More awareness for memory, language deficits than

abstract thinking and social deficits• May have good intellectual understanding of deficitsand still be unable to use this knowledge to self-regulate• Cultural component

– Harder to admit deficits in areas more valued by your culture

Toglia & Kirk, 2000

Overcoming Obstacle #1

• Restructuring of one’s beliefs of strengths and limitations

– Pre-injury beliefs New beliefs

– “Getting to know oneself” again

– Learn best from “mastery experiences”

• Guided mastery

Obstacle #3: Memory Deficits

• Remembering when and how to use strategies

– Systematic instruction

– Ample opportunities for practice

– Negotiate partner cueing (Ylvisaker, 2006)

– Negotiate natural, sustainable visual aids

– Daily reminder

• Consider a different approach if memory deficits are severe

– Focus on communication partner training

Awareness Training

• Self-monitoring skills more likely to emerge on familiar tasks that are “just the right amount” of challenge

– Too difficult fail to integrate

– Too easy fail to generalize to real tasks

• Structure experience so person can discover errors themselves

– And feel control and mastery over performance

• Structured methods of self-questioning, self-evaluation

• Video reflection, feedback

Obstacle #2: Apathy“Denise”

• Motivational interviewing– Not a strong evidence base for clients with – apathy (Brett et al., 2015)

• Provide personalized information on injury• Behavioral contracting

– Specific– Written

• Contingent rewards– Token economy

• For non-compliant behaviors– Antecedent management– Barrier reduction

• Reminder call before each session• Modify task demands (unloading vs. loading the dishwasher)

– Graded confrontation (indirect, then direct)Brett et al., 2015

Wrap Up

Three collaborative approaches for treating social communication following ABI are person-centered goalsetting, communication partner training, and context-sensitive intervention.

Common obstacles and ways to overcome them are___

Helpful communication partner strategies are ____

Questions?

Contact: heidii@uoregon.edu

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References

Abreu, B. C., Zhang, L., Seale, G., Primeau, L. & Jones, J. S. (2002). Interdisciplinary meetings: Investigating the collaboration between persons with brain injury and treatment teams. Brain Injury, 16(8), 691-704. https://doi.org/10.1080/02699050210128942

American Speech Language Hearing Association, n.d. Components of Social Communication. https://www.asha.org/uploadedFiles/ASHA/Practice_Portal/Clinical_Topics/Social_Communication_Disorders_in_School-Age_Children/Components-of-Social-Communication.pdf

Berquist, T. F., Micklewright, J. L., Yutsis, M., Smigielski, J. S., Gehl, C., & Brown, A. W. (2012). Achievement of client-centered goals by persons with acquired brain injury in comprehensive day treatment is associated with improved functional outcomes. Brain Injury, 26(11), 1307-1314. https://doi.org/10.3109/02699052.2012.706355

Brett, C. E., Sykes, C., & Pires-Yfantouda, R. (2015). Interventions to increase engagement with rehabilitation in adults with acquired brain injury: A systematic review. Neuropsychological Rehabilitation 27(6), 1-24. https://doi.org/10.1080/09602011.2015.1090459

Finch, E., Copley, A., Cornwell, P., & Kelly, C. (2016). Systematic review of behavioral interventions targeting social communication difficulties after traumatic brain injury. Archives of Physical Medicine and Rehabilitation, 97, 1352-65. https://doi.org/10.1016/j.apmr.2015.11.005

Gordon, R., G., & Duff, M. C. (2016). Incorporating principles of the collaborative contextualised intervention approach with the empirical study of learning and communication in traumatic brain injury. Aphasiology, 30(12), 1461-1482. https://doi.org/10.1080/02687038.2015.1136050

Grant, M., & Ponsford, J. (2014). Goal Attainment Scaling in brain injury rehabilitation: Strengths, limitations and recommendations for future applications. Neuropsychological Rehabilitation, 24(5), 661-677. https://doi.org/10.1080/09602011.2014.901228

References

MacDonald, S. (2017). Introducing the model of cognitive-communication competence: A model to guide evidence-based communication interventions after brain injury. Brain Injury, 31 (13-14), 1760-1780

https://doi.org/10.1080/02699052.2017.1379613

MacLennan, D.L., Cornis-Pop, M., Picon-Nieto, L., and Sigford, B. (2002). The prevalence of pragmatic communication impairments in traumatic brain injury. Poster presentation from the 2002 Brain Injury Association Conference.

Medley, A. R., & Powell, T. (2010). Motivational interviewing to promote self-awareness and engagement in rehabilitation following acquired brain injury: A conceptual review. Neuropsychological Rehabilitation, 20(4), 481-508. https://doi.org/10.1080/09602010903529610

Miller, W. R. and Rollnick, S. (1991) Motivational interviewing: Preparing people to change addictive behavior. New York: Guilford Press.

Plant, S. E., Tyson, S. F., Kirk, S., & Parsons, J. (2016). What are the barriers and facilitators to goal-setting during rehabilitation for stroke and other acquired brain injuries? A systematic review and meta-synthesis. Clinical Rehabilitation, 30(9), 921-930. https://doi.org/10.1177/0269215516655856

Togher, L. (2013). Improving communication for people with brain injury in the 21st century: The value of collaboration. Brain Impairment, 14(1), 130-138. https://doi.org/10.1017/BrImp.2013.3

Togher, L., McDonald, S., Tate, R., Power, E., & Rietdijk, R. (2013). Training communication partners of people with severe traumatic brain injury improves everyday conversations: A multicenter single blind clinical trial. Journal of Rehabilitation Medicine, 45, 637-545. http://doi.org/10.2340/16501977-1173

Togher, L., McDonald, S., Tate, R., Power, E., & Rietdijk, R. (2009). Training communication partners of people with traumatic brain injury: Reporting the protocol for a clinical trial. Brain Impairment, 10(2), 188-204.

https://doi.org/10.1375/brim.10.2.188

Togher, L., McDonald, S., Tate, R., Power, E., Ylvisaker, M., & Rietdijk, R. (2010). TBI Express: Communication Training Manual. Australian Society for the Study of Brain Impairment, Sydney: Australia

References

Togher, L., Power, E., Tate, R., McDonald, S., & Rietdijk, R. (2010). Measuring the social interactions of people with traumatic brain injury and their communication partners: The adapted Kagan scales. Aphasiology, 24 (6-8), 914-927.

Toglia, J. & Kirk, U. (2000). Understanding awareness deficits following brain injury. Neurorehabilitation, 15 (2000), 57-70

Ylvisaker, M. (2006). Self-coaching: A context-sensitive, person-centered approach to social communication after traumatic brain injury. Brain Impairment, 7(3), 246-258. https://doi.org/10.1375/brim.7.3.246

Ylvisaker, M., & Feeney, T. (1998). Collaborative brain injury intervention: Positive everyday routines. San

Diego: Singular Publishing Group.

Ylvisaker, M. & Feeney, T. (2000). Reflections on Dobermanns, poodles, and social rehabilitation for difficult-to-serve individuals with traumatic brain injury. Aphasiology, 14 (4), 407-431

Graphics from https://pngtree.com, www.pexels.com

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PRAGMATICS RATING SCALE

D. MacLennan, M.A.

I. Non-Verbal Aspects of Communication

INTELLIGIBILITY

__________________________________________________________

1 2 3 4 5

Frequent distortion of

words. Speech is 0-

5% intelligible.

Moderate distortion

of words. Speech is

36-65% intelligible.

Normal or near-

normal clarity of

words. Speech is

95-100%

intelligible.

FLUENCY

__________________________________________________________

1 2 3 4 5

Communication is

consistently

characterized by

incomplete

utterances, false

starts, and cut-off

words. Normal

fluency occurs 0-5%

of the time.

Communication is

characterized by few

incomplete

utterances, false

starts and cut-off

words. Normal

fluency occurs 36-65%

of the time.

Normal fluency

occurs 95-100% of

the time.

PROSODY

__________________________________________________________

1 2 3 4 5

Severely reduced

variation of

intonation and stress.

Normal prosody 0-5%

of the time.

Moderately reduced

variation of intonation

and stress. Normal

prosody 36-65% of

the time.

Normal variation

of intonation and

stress 95-100% of

the time.

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FACIAL EXPRESSION

__________________________________________________________

1 2 3 4 5

Severely reduced

variation of facial

expression. Normal

facial expression 0-5%

of the time

Moderately reduced

variation of facial

expression. Normal

facial expression 36-

65% of the time.

Normal variation

of facial

expression

95-100% of the

time.

EYE CONTACT

__________________________________________________________

1 2 3 4 5

Severely reduced eye

contact. Normal eye

contact 0-5% of the

time

Moderately reduced

eye contact. Normal

eye contact 36-65% of

the time.

Normal variation

of eye contact 95-

100% of the time.

GESTURE

__________________________________________________________

1 2 3 4 5

Minimal use of gesture

or unusually frequent

or bizarre gestures that

distract from

conversation. Normal

use of gesture occurs

0-5% of the time.

Limited use of gesture

or moderate

occurrence of bizarre

gestures that distract

from conversation.

Normal use of gesture

occurs 36-65% of the

time.

Normal use of

gesture to support

communication

95-100% of the

time.

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II Propositional Aspects of Communication

COHESION

__________________________________________________________

1 2 3 4 5

Communication is

consistently vague

and lacks adequate

information or clear

referents 95-100% of

the time.

Communication is

moderately vague and

lacks adequate

information or clear

referents 36-65% of

the time.

Communication is

consistently clear

with ample

information for

understanding

and clear

referents 0-5% of

the time.

RELEVANCE (topic maintenance)

__________________________________________________________

1 2 3 4 5

Communication

is consistently

irrelevant to topic.

Conversation is

relevant 0-5% of the

time.

Communication is

moderately irrelevant

to topic.

Conversation is

relevant 36-65% of

the time.

Communication is

consistently

relevant to topic

95-100% of the

time.

ELABORATION (topic maintenance)

__________________________________________________________

1 2 3 4 5

Severely reduced

topic elaboration.

Produces consecutive

utterances related to

a given topic or

responds to

communication

partner’s comments

0-5% of the time.

Moderately reduced

topic elaboration.

Produces consecutive

utterances related to

a given topic or

responds to

communication

partner’s comments

36-65% of the time.

Normal

elaboration of

topic. Produces

consecutive

utterances related

to a given topic or

responds to

communication

partner’s

comments 95-

100% of the time.

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INITIATION (quantity/conciseness)

__________________________________________________________

1 2 3 4 5

Severely reduced

initiation of new

topics. Initiates new

topic where

appropriate 0-5% of

the time.

Moderately reduced

initiation of new

topics. Initiates new

topic where

appropriate 36-65%

of the time.

Normal initiation

of new topics.

Initiates new

topics where

appropriate 95-

100% of the time.

VERBOSITY (quantity/conciseness)

__________________________________________________________

1 2 3 4 5

Communication is

consistently

characterized by

excessive detail or

unnecessary

repetition of

information.

Appropriate detail

and repetition 0-5%

of the time.

Communication is

characterized by

moderately excessive

detail or unnecessary

repetition of

information.

Appropriate detail

and repetition 36-65%

of the time.

Communication

has appropriate

amount of detail

and repetition of

information 95-

100% of the time.

III Interactional Aspects of Communication

APPROPRIATENESS (topic management)

__________________________________________________________

1 2 3 4 5

Severe impairment in

selecting topics

appropriate to

context. Topic is

appropriate to

situational context 0-

5% of the time.

Moderate impairment

in selecting topics

appropriate to

context. Topic is

appropriate to

situational context

36-65% of the time.

Topics introduced

in conversation

are appropriate to

situational context

95-100% of the

time.

16

RESPONSIVENESS (turn-taking)

__________________________________________________________

1 2 3 4 5

Severely increased

response latency.

Normal response

latency occurs

0-5% of the time

Moderately increased

response latency.

Normal response

latency occurs 36-65%

of the time.

Normal response

latency occurs

95-100% of the

time.

INTERRUPTION (turn-taking)

__________________________________________________________

1 2 3 4 5

Consistent

interruption of

communication

partner. Interruption

occurs

95-100% of the time.

Moderate

interruption of

communication

partner. Interruption

occurs

36-65% of the time.

Minimal

interruption of

communication

partner.

Interruption

occurs 0-5% of the

time.

FEEDBACK

__________________________________________________________

1 2 3 4 5

Severe reduction of

verbal or non-verbal

response to

communication

partner. Appropriate

feedback occurs 0-5%

of the time

Moderately reduced

verbal or non-verbal

response to

communication

partner. Appropriate

feedback occurs 36-

65% of the time.

Normal verbal or

non-verbal

response to

communication

partner.

Appropriate

feedback occurs

95-100% of the

time.

17

REPAIR

__________________________________________________________

1 2 3 4 5

Severely reduced

repair of

conversational

breakdown.

Conversational repair

occurs 0-5% of the

time where

appropriate

Moderately reduced

repair of

conversational

breakdown. Repair

occurs 36-65% of the

time where

appropriate.

Normal repair of

conversational

breakdown.

Conversational

repair occurs 95-

100% of the time

where appropriate

18

Priorities

We’ve talked about several things you might be interested in

working on with us. What seems to be most important?

______________________________________

______________________________________

______________________________________

______________________________________

______________________________________

______________________________________

19

Measurement

• How often?

o In a week, in a day, in an hour, in 15

minutes?

• How well?

o Accuracy

o Performance

• How much time does it take to do something?

o Efficiency

• Self-rating, 1-5

o Rate your effort (when you do the task)

o Rate your confidence (in

o being able to do the task)

• Who will measure this?

• How will you measure this?

20

Goal #1 At this level, I would

consider this

problem solved

Where I hope to be

after ____

weeks/months

Where I hope to be

after ____

weeks/months

Where I am now

Goal #2

At this level, I would

consider this

problem solved

Where I hope to be

after ____

weeks/months

Where I hope to be

after ____

weeks/months

Where I am now