Cognitive Rehabilitation Therapy
for Traumatic Brain Injury

Evaluating the Evidence

Committee on Cognitive Rehabilitation Therapy for Traumatic Brain Injury

Rebecca Koehler, Erin E, Wilhelm, Ira Shoulson, Editors

Board on the Health of Select Populations

INSTITUTE OF MEDICINE

OF THE NATIONAL ACADEMES

THE NATIONAL ACADEMIES PRESS
Washington, D.C.
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Cognitive Rehabilitation erapy for Traumatic Brain Injury Evaluating the Evidence Committee on Cognitive Rehabilitation Therapy for Traumatic Brain Injury Rebecca Koehler, Erin E. Wilhelm, Ira Shoulson, Editors Board on the Health of Select Populations

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THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This study was supported by Contract No. HHSP23320042509XI between the National Academy of Sciences and the U.S. Department of Defense. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project. International Standard Book Number 13: 978-0-309-21818-4 International Standard Book Number 10: 0-309-21818-7 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap. edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2011 by the National Academy of Sciences. All rights reserved. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. Cover credit: The middle image is a U.S. Air Force photo by Staff Sgt. Robert Barney/ Released. Suggested citation: IOM (Institute of Medicine). 2011. Cognitive Rehabilitation Therapy for Traumatic Brain Injury: Evaluating the Evidence. Washington, DC: The National Academies Press.

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“Knowing is not enough; we must apply. Willing is not enough; we must do.” — Goethe Advising the Nation. Improving Health.

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The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and techni- cal matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding en- gineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sci- ences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congres- sional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Acad- emy’s purposes of furthering knowledge and advising the federal government. Func- tioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is adminis- tered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Re- search Council. www.national-academies.org

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COMMITTEE ON COGNITIVE REHABILITATION THERAPY FOR TRAUMATIC BRAIN INJURY IRA SHOULSON (Chair), Professor of Neurology, Pharmacology and Human Science, and Director, Program for Regulatory Science and Medicine, Georgetown University, Washington, DC REBECCA A. BETENSKY, Professor of Biostatistics, Harvard School of Public Health, Harvard University, Boston, MA PETER COMO, Lead Reviewer/Neuropsychologist, U.S. Food and Drug Administration, Silver Spring, MD RAY DORSEY, Associate Professor of Neurology, The Johns Hopkins University, Baltimore, MD CHARLES DREBING, Acting Mental Health Service Line Manager, Bedford VA Medical Center, Bedford, MA ALAN I. FADEN, David S. Brown Professor, Departments of Anesthesiology, Anatomy and Neurobiology, Neurosurgery, and Neurology, Director, STAR Organized Research Center, University of Maryland School of Medicine ROBERT T. FRASER, Professor of Rehabilitation Medicine, University of Washington/Harborview Medical Center, Seattle, WA TAMAR HELLER, Professor and Department Head, Department of Disability and Human Development, University of Illinois at Chicago RICHARD KEEFE, Professor of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC MARY R. T. KENNEDY, Associate Professor, Department of Speech- Language-Hearing Sciences, University of Minnesota, Minneapolis HARVEY LEVIN, Professor and Director of Research, Department of Physical Medicine & Rehabilitation, Baylor College of Medicine; Director of the Center of Excellence for Traumatic Brain Injury, Michael E. De Bakey Veterans Affairs Medical Center, Houston, TX CYNTHIA D. MULROW, Professor of Medicine, University of Texas Health Science Center at San Antonio, TX HILAIRE THOMPSON, Assistant Professor, School of Nursing, University of Washington, Seattle JOHN WHYTE, Director, Moss Rehabilitation Research Institute, Elkins Park, PA Consultants JENNIFER J. VASTERLING, Chief of Psychology, VA Boston Healthcare System; Professor of Psychiatry, Boston University School of Medicine, MA BARBARA G. VICKREY, Professor and Vice Chair, Department of Neurology, University of California, Los Angeles v

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IOM Study Staff REBECCA N. KOEHLER, Study Director ERIN E. WILHELM, Associate Program Officer ALICIA JARAMILLO-UNDERWOOD, Program Assistant JON Q. SANDERS, Program Associate ANDREA COHEN, Financial Associate FREDERICK (RICK) ERDTMANN, Director, Board on the Health of Select Populations

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Reviewers This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with proce- dures approved by the National Research Council’s Report Review Commit- tee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: Charles H. Bombardier, University of Washington School of Medicine Diana D. Cardenas, University of Miami Keith Cicerone, JFK-Johnson Rehabilitation Institute Chris Giza, University of California, Los Angeles Wayne Gordon, Mount Sinai School of Medicine Tessa Hart, Moss Rehabilitation Research Institute Bruce Miller, University of California, San Francisco Mark Sherer, TIRR Memorial Hermann McKay Moore Sohlberg, University of Oregon Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions vii

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viii REVIEWERS or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by Dan G. Blazer, Duke University Medical Center, and Nancy E. Adler, University of California, San Francisco. Appointed by the National Research Council and Institute of Medicine, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Re- sponsibility for the final content of this report rests entirely with the author- ing committee and the institution.

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Preface Traumatic brain injury (TBI) is a too common and disabling occurrence in civilian and military life, estimated to annually affect 10 million people worldwide. The Institute of Medicine (IOM) has a long-standing role of providing guidance to the Department of Defense (DoD) on the health and well-being of services members and their families. At the request of DoD, the current study represents a concentrated endeavor by the Committee on Cognitive Rehabilitation Therapy for Traumatic Brain Injury to compre- hensively evaluate the value of cognitive rehabilitation therapy (CRT) as a therapeutic intervention for traumatic brain injury. The United States military is currently engaged in ongoing operations in Afghanistan (Operation Enduring Freedom) and Iraq (Operation Iraqi Free- dom). Conflicts in these war zones have been characterized by more explo- sive weaponry and other aggressive tactics, placing members of the military at greater risk for TBI, the “signature wound” of these wars. Recovering and returning service members with TBI may face long-term challenges in rehabilitation and reintegration to everyday life. These challenges to injured individuals also affect their families and communities. Survivors of TBI re- quire ongoing support systems to care for and cope with physical injuries, cognitive impairment and coexisting disabilities such as posttraumatic stress disorders. An effective and reliable health care infrastructure and evidence- based treatment and rehabilitation policies must be in place to achieve effective recovery and a return to optimal functioning and productivity. The public increasingly is confronted with and better recognizes the often enduring and serious consequences of TBI and the need for providing the most effective treatments for those who serve our country in harm’s way. ix

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x PREFACE The committee sought to provide a scientific framework to evaluate current research and practices related to CRT. To evaluate the value of CRT for TBI, the committee iteratively developed criteria for inclusion of published scientific reports and reviewed and analyzed some 88 studies to inform our findings on specific domains such as attention, executive func- tion, language and social communication, and memory, as well as multi- modal or comprehensive CRT programs. We are honored to have been of service in providing DoD with a com- prehensive evidence-based review of CRT for TBI. This was a timely review, both in terms of the relevance of the topic and relatively brief time allocated to complete the review and our report. I am deeply appreciative of the expert work of our dedicated committee members and their extraordinary commitment and contributions to the task at hand. Over a course of about 6 months, we convened six in-person committee meetings, two open meet- ings including scientific presentations, and an abundance of teleconferences and email exchanges. We trust that this report assists not only DoD in its ef- forts to care for recovering and returning service members, but also informs the broader research community about the value of cognitive rehabilitation therapy for TBI sustained in both military and civilian settings. The committee extends its appreciation to the many people who pre- sented information at its open meeting and to our dedicated IOM staff: Rebecca Koehler, Erin Wilhelm, Alicia Jaramillo-Underwood, and Jon Sanders. We also thank Mary Ferraro and Andy Packel at the Moss Re- habilitation Institute (Philadelphia), who expertly abstracted information from reviewed research reports. We also thank consultants to the commit- tee, Jennifer Vasterling and Barbara Vickrey, for their contributions in the development of several chapters of the report. A special appreciation is due to the patients, their families, and clinicians who strive together to combat and recover from the disabling and often devastating consequences of TBI. Ira Shoulson, Chair Committee on Cognitive Rehabilitation Therapy for Traumatic Brain Injury

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Contents ACRONYMS AND ABBREVIATIONS xvii SUMMARY 1 PART I: BACKGROUND 1 INTRODUCTION 21 Scope of the Report, 22 Traumatic Brain Injury, 23 Consequences of TBI, 26 Treatment, 28 The Military Health System, 30 Conclusion, 32 References, 33 2 TRAUMATIC BRAIN INJURY 37 Classification Schemes, 38 Heterogeneity, 42 Measures of Outcome, 49 Conclusion, 52 References, 52 3 FACTORS AFFECTING RECOVERY 59 Preinjury Conditions, 60 xi

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xii CONTENTS Comorbidities, 61 Contextual Factors, 67 Conclusion, 69 References, 70 4 DEFINING COGNITIVE REHABILITATION THERAPY 75 The Breadth of Rehabilitation, 75 An Evolving Definition of CRT, 77 Conclusion, 86 References, 86 5 STATE OF PRACTICE AND PROVIDERS OF COGNITIVE REHABILITATION THERAPY 89 State of Practice, 89 Providers, 94 Conclusion, 110 References, 110 PART II: REVIEW OF THE EVIDENCE 6 METHODS 115 Literature Review, 115 Evaluation of the Evidence, 118 Quality of Study Designs, 121 Organization of the Evidence Chapters, 123 References, 123 7 ATTENTION 125 Overview, 125 Moderate-Severe TBI, 126 Conclusions: Attention, 135 References, 136 8 EXECUTIVE FUNCTION 137 Overview, 137 Awareness, 137 Conclusions: Awareness, 152 Non-Awareness, 153 Conclusions: Non-Awareness, 158 References, 160 9 LANGUAGE AND SOCIAL COMMUNICATION 163 Overview, 163

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xiii CONTENTS Chronic, Moderate-Severe TBI, 164 Conclusions: Language and Social Communication, 171 References, 173 10 MEMORY 175 Overview, 175 Internal Memory Strategies, 176 External Memory Strategies, 184 Combined Memory Strategies: Internal and External, 189 Restorative Strategies, 191 Conclusions: Memory, 193 References, 211 11 MULTI-MODAL OR COMPREHENSIVE COGNITIVE REHABILITATION THERAPY 213 Overview, 213 Subacute Phase of Recovery, 214 Conclusions: Subacute, Multi-Modal/Comprehensive CRT, 217 Chronic Phase of Recovery, 218 Conclusions: Chronic, Multi-Modal/Comprehensive CRT, 224 References, 241 12 TELEHEALTH TECHNOLOGY 243 Overview, 243 CRT Applied Through Telehealth Technology, 243 Conclusions: Telehealth Technology, 247 References, 247 13 ADVERSE EVENTS OR HARM 249 Overview, 249 Potential for Adverse Events or Harm from CRT, 249 Conclusions: Adverse Events or Harm, 251 References, 251 PART III: RECOMMENDATIONS 14 DIRECTIONS 255 Synthesis of Evidence Review, 255 Recommendations, 258 Conclusion, 268 References, 269

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xiv CONTENTS APPENDIXES A Comparative Effectiveness and Implementation Research for Neurocognitive Disorders 273 B Workshop Agendas 283 C Recent and Ongoing Clinical Trials: CRT for TBI 287 D Biosketches of Committee Members and Staff 325

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Tables, Figures, and Boxes TABLES S-1 Conclusions by Cognitive Domain and Multi-Modal/Comprehen- sive CRT, 11 2-1 Classification of Mild, Moderate, and Severe Traumatic Brain Injury, 40 4-1 Definitions of Cognitive Rehabilitation Therapy by Organization, 78 5-1 CRT Providers: Services, Practice Requirements, and Professional Setting, 96 6-1 Definitions of Acute, Subacute, and Chronic Phases of Recovery Post-TBI, 118 6-2 Study Design by Treatment Domain or Strategy, 119 7-1 Evidence Table: Attention, 127 8-1 Evidence Table: Executive Function, 139 9-1 Evidence Table: Language and Social Communication, 165 10-1 Evidence Table: Memory, 199 10-2 Internal Memory Strategies, 177 xv

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xvi TABLES, FIGURES, AND BOXES 10-3 External Memory Strategies, 184 10-4 Combined Memory Strategies, 189 10-5 Restorative Memory Strategies, 192 11-1 Evidence Table: Multi-Modal/Comprehensive CRT, 227 11-2 Studies in the Subacute Phase of Recovery, 214 11-3 Studies in the Chronic Phase of Recovery, 219 14-1 Overall Conclusions by Cognitive Domain and Multi-Modal/ Comprehensive CRT, 256 14-2 Definitions of Acute, Subacute, and Chronic TBI Recovery, 257 FIGURES 1-1 Number of U.S. service members with TBI, by severity, 25 1-2 WHO-IC Model of Disablement, 27 3-1 Factors affecting initial response to TBI and recovery from TBI, 60 4-1 Model for modular CRT, 81 4-2 Model for multi-modal/comprehensive CRT, 82 A-1 Model for multi-modal/comprehensive CRT, 274 A-2 Clinical research continuum, 276 A-3 Refined research-implementation pipeline, 277 BOXES S-1 Statement of Task, 2 S-2 Evidence Grades, 10 1-1 Statement of Task, 23 1-2 Department of Defense Definition of Traumatic Brain Injury, 24 6-1 Inclusion and Exclusion Criteria, 117 6-2 Evidence Grades, 121

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Acronyms and Abbreviations AAD Assessment of awareness of disability AANN American Association of Neuroscience Nurses ACBIS Academy of Certified Brain Injury Specialists ACFI Assessment of Client Functioning Inventory ACOTE Accreditation Council for Occupational Therapy Education ACRM American Congress of Rehabilitation Medicine ADHD Attention deficit hyperactivity disorder ADL Activities of daily living AIM Assessment of Intentional Memory AIP Awareness Intervention Program AMPS Assessment of Motor and Process Skills ApoE Apolipoprotein E APT Attention Process Training ARN Association of Rehabilitation Nurses ASHA American Speech-Language-Hearing Association BI-ISIG Brain Injury Interdisciplinary Special Interest Group BINT Blast-induced neurotrauma BRISS–R Behaviorally Referenced Rating System of Intermediary Social Skills–Revised bTBI Blast-induced traumatic brain injury BVRT Benton Visual Retention Test CAA Council on Academic Accreditation CACR Computer-assisted cognitive rehabilitation xvii

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xviii ACRONYMS AND ABBREVIATIONS CAMG Computer-Assisted Memory Training Group CAPTE Commission on Accreditation of Physical Therapy Education CBIS Certified Brain Injury Specialist CBT Cognitive behavioral therapy CDC Centers for Disease Control and Prevention CDE Common data element CFT Rey-Osterrieth Complex Figure Test CG Control group CHART–R Craig Handicap Assessment and Reporting Technique–Revised CHART–SF Craig Handicap Assessment and Reporting Technique– Short Form CIQ Community Integration Questionnaire CNRN Certified Neuroscience Registered Nurse CO Cognitive orthosis COPM Canadian Occupational Performance Measure COWAT Controlled Oral Word Association Test CP Clinical psychologist CPT Continuous Performance Test CRBC Cognitive Retraining Behavior Checklist CRRN Certified Rehabilitation Registered Nurse CRT Cognitive Rehabilitation Therapy CS Constraint seeking CSG Cognitive skills group CT Computed tomography CVLT California Verbal Learning Test DARE Database of Reviews of Effects DASS Depression, Anxiety and Stress Scale DMDC Defense Manpower Data Center DO Diary only DoD Department of Defense DRS Disability Rating Scale DSIT Diary and Self-Instructional Training DTI Diffusion Tensor Imaging DVBIC Defense and Veterans Brain Injury Center ECRI Emergency Care Research Institute EEG Electroencephalogram EL Errorless learning EMF Everyday memory failures EMQ Everyday Memory Questionnaire

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xix ACRONYMS AND ABBREVIATIONS ERIC Education Resources Information Center FAM Functional assessment measure FANCI First Steps Acute Neurobehavioral and Cognitive Intervention FCSUS Frequency of Cognitive Strategy Usage Scale FIM Functional independence measure FITBIR Federal Interagency Traumatic Brain Injury Research fMRI Functional magnetic resonance imaging FNM Face-name method FRsBe Frontal Systems Behavior Scale GAS Goal Attainment Scaling GCS Glasgow Coma Scale GMT Goal Management Training GOS Glasgow Outcome Scale GOS-E Extended Glasgow Outcome Scale GST General Stimulation Training HKLLT Hong Kong List Learning Test HRTB Halstead-Reitan Neuropsychological Test Battery HVLT–R Hopkins Verbal Learning Test–Revised IADL Instrumental activities of daily living ICF International Classification of Functioning, Disability, and Health ICIDH International Classification of Impairments, Disabilities and Handicaps IED Improvised explosive device IRB Institutional review board IOM Institute of Medicine ISMT Interactive strategy modeling training IT Information Technology IVA-CPT Integrated Visual and Auditory Continuous Performance Test KAS Katz Adjustment Scale KAS–R Katz Adjustment Scale–Relative Report Form KAS-R1 Katz Adjustment Scale, modified form R1 LAP Learning activities packet LCFS Levels of Cognitive Functioning Scale LCSW Licensed Clinical Social Worker

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xx ACRONYMS AND ABBREVIATIONS LM Logical memory LOC Loss of consciousness LTM Long-term memory MAC–F Memory Assessment Clinics ratings scales–Family MAC–S Memory Assessment Clinics ratings scales–Self MANOVA Multivariate analysis of variance MCI Mild cognitive impairment MCQ Memory Compensation Questionnaire MEPSM Means-Ends Problem-Solving Measure MHS Military Health System MI Metacomponential Interview MOL Method of loci MPAI-3 Mayo-Portland Adaptability Inventory III MRI Magnetic resonance imaging MTBI Mild traumatic brain injury MSW Master of Social Work NART National Adult Reading Test NCLEX-RN National Council Licensure Examination for Registered Nurses NCSE Neurobehavioral Cognitive Status Examination NFI Neurobehavioral Functioning Inventory NICHD National Institute of Child Health and Human Development NIDRR National Institute on Disability and Rehabilitation Research NIH National Institutes of Health NR Neurorehabilitation program OEF Operation Enduring Freedom OIF Operation Iraqi Freedom ORM Orientation Remedial Module OT Occupational therapist OTR Occupational therapist registered PASAT Paced Auditory Serial Addition Test PASAT–R Paced Auditory Serial Addition Test–Revised PCS Post-concussion syndrome PCSS Personal Conversational Style Scale PDA Personal digital assistant PDBS Partner Directed Behavior Scale PET Positron emission tomography

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xxi ACRONYMS AND ABBREVIATIONS PFIC Profile of Functional Impairment in Communication PQOL Perceived Quality of Life PQRST Preview, Question, Repeat, State, and Test PROM Patient Reported Outcome Measures PRPP Perceive, Recall, Plan, and Perform PSQ Problem Solving Questionnaire PTA Posttraumatic amnesia PTSD Posttraumatic stress disorder QCIQ Quality of Community Integration Questionnaire RAPS Rapid Assessment of Problem Solving RAVLT–M Rey Auditory Verbal Learning Test–Modified RBMT Rivermead Behavioural Memory Test RCT Randomized controlled trial RIS Ridiculously imaged story RITS Rehabilitation Intensity of Therapy Scale RLTLT Ruff-Light Trail Learning Test RN Registered nurse RPM Raven’s Progressive Matrices SADI Self Awareness of Deficits Interview SART Sustained Attention to Response Test SCL–90 R Symptom Checklist–90 Revised SCSQ–A Social Communication Skills Questionnaire–Adapted SES Socioeconomic status SIT Self-instruction training SLP Speech-language pathologist SPRS Sydney Psychosocial Reintegration Scale SPRS–Relative Sydney Psychosocial Reintegration Scale–Relative Ratings SPRS–Self Sydney Psychosocial Reintegration Scale–Self Ratings SPSS Social Performance Survey Schedule SPSVM Social Problem-Solving Video Measure SR Spaced Retrieval SRSI Self-regulation skills interview SS/MB Single-subject, multiple baseline SUD Substance use disorders SWLS Satisfaction with Life Scale TAI Traumatic axonal injury TAMG Therapist Administered Memory Training Group TAP Test for Attentional Performance TASIT The Awareness of Social Interference Test

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xxii ACRONYMS AND ABBREVIATIONS TBI Traumatic brain injury TMS Transcranial magnetic stimulation TPM Time Pressure Management TOT Temporal Orientation Test UCSS Usefulness of Cognitive Strategy Scale USUHS Uniformed Services University of the Health Sciences VA Department of Veterans Affairs VAMC Veterans Affairs’ Medical Center VHA Veterans Health Administration VPA Visual paired associates WA Working alliance WAIS Wechsler Adult Intelligence Scale WAIS–R Wechsler Adults Intelligence Scale–Revised WCST Wisconsin Card Sorting Test WHO World Health Organization WHO-ICF World Health Organization’s International Classification of Functioning, Disability, and Health WMS–R Wechsler Memory Scale–Revised WMT Working Memory Training WRAMC Walter Reed Army Medical Center