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ONGOING PROJECT-ORIENTED INTERVENTION FOR CHILDREN AND ADULTS WITH DISABILITY: COLLABORATION AND APPRENTICESHIP

Revised: 9/05

Mark Ylvisaker, PhD <ylvisakm@mail.strose.edu> The College of Saint Rose Albany, New York

GENERAL FRAMEWORK: TWO COMPETING INTERVENTION MODELS


1. THE TRADITIONAL MODEL FOR REHABILITATION AND SPECIAL EDUCATION: Attempt to eliminate or reduce the underlying impairment with 1st restorative/training exercises (assuming that success will automatically reduce or eliminate the associated disability) (activity/participation reduction). If the impairment and associated disability (activity/participation reduction) 2nd persist, then address the disability with compensatory strategy training. 3rd If the disability (activity/participation reduction) persists, then focus on context/environmental compensations (e.g. modify the tasks, modify the environment, increase the supports provided by others in the environment). AN ALTERNATIVE MODEL: (Modified with permission from Ylvisaker, M., Feeney, J., & Feeney, T. (1999). An everyday approach to long-term rehabilitation after traumatic brain injury. In B. Cornett (Ed.), Clinical practice management in speech-language pathology: Principles and practicalities (pp. 117-162). Gaithersburg, MD: Aspen Publishing Co.) Identify what is working and what is not working for the individual in everyday 1st routines. nd 2 Identify what changes - including changes in activities, in the environment, in the support behavior of others (including their understanding, expectations, communication style, and other supportive behaviors), and in the individuals own behavior (including compensatory strategies) - hold the potential to change negative routines into positive routines and build repertoires of successful behavior. Identify how those changes in everyday routines can be become motivating for 3rd the individual and for critical everyday people in that environment. th Implement whatever supports are necessary for intensive practice of positive 4 routines in real-world contexts, with the goal of successful participation in meaningful activities, habituation of positive behaviors, and internalization/ automatization of strategic behaviors. Systematically withdraw supports as it becomes possible to do so, knowing that 5th the need for supports may again increase with fluctuation in life stressors. Using WHO language, the alternative model addresses impairment, activity/participation, and context simultaneously OR reverses the traditional hierarchy and addresses participation via context modifications first, then activity improvement with compensatory procedures, and over time the underlying impairment. The Project Approach fits more comfortably with the alternative model than with the traditional model.

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DEFINITION OF PROJECT
As the term is used here, a project is a structured activity that: Focuses on a personally meaningful goal, ideally a goal that includes a concrete product Requires deep processing and thorough analysis/investigation of many dimensions of a problem or activity Requires considerable planning and organizing activity, thereby creating a meaningful context for practicing the use of organizational and memory strategies or prosthetics and for expert mediation of organizational thinking Creates a meaningful work context for practicing all aspects of executive functioning (including reflection on personal strengths and needs, goal setting, planning, initiating, inhibiting, monitoring and evaluating, strategic thinking and behavior, flexibility) Creates a meaningful context for practicing language and communication skills, including peer-related communication Creates a meaningful context for practicing cooperative effort, positive social interaction, and behavioral self-regulation Requires several days to several months to complete, thereby integrating the individuals activity from day to day and week to week Ideally integrates activities in more than one context of the persons life. For example, the project may be addressed in more than one scheduled therapy (e.g. both OT and speech) and may require effort during what would otherwise be down time (e.g. on the nursing unit of a rehabilitation hospital; in the evening at home) Ideally creates an expert role for the person with disability, thereby helping the person transform a self-concept that may be dominated by a sense of incompetence. Ideally creates a helper role/producer for the person with disability, thereby helping the person transform a self-concept that may be dominated by a sense of helplessness and passivity. NOTE 1: Our use of the term project and the overall approach to project-oriented intervention is related, both theoretically and procedurally, to the Project Approach to early childhood education popularized by Lilian Katz and Sylvia Chard (and used in Italy for several decades). They have a large number of publications on the Project Approach, including their most recent book: Katz, L.G., & Chard, S.C. (2000). Engaging Childrens Minds: The Project Approach (2nd Edition). Stamford, CN: Ablex Publishing Corp. There are also important differences between projects as we use the term and projects as discussed in the early childhood education literature. NOTE 2: The concept of project is related to but different from the concept of theme. Because themes are more abstract ways to unify activities (e.g. a season theme, holiday theme, etc.) and dont necessarily involve meaningful products or an expert/helper role for the person with disability, they do not contribute to the same goals that projects (as we use the term) contribute to. NOTE 3: The concept of project is related to but different from the concept of job or responsibility. However, many of the goals that can be achieved using projects can also be

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achieved using jobs or responsibilities. NOTE 4: Projects are typically used to complement other approaches to intervention and support.

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THEORETICAL SUPPORT FOR PROJECT-ORIENTED INTERVENTION: INDIVIDUALS WITH BRAIN INJURY AND CHILDREN WITH DISABILITIES
NOTE: Several of the points that follow include specific reference to impairment related to damage to or immaturity of the frontal lobes of the brain. Frontal lobe impairment is particularly common in individuals with traumatic brain injury. In addition, several congenital neurologic syndromes are strongly associated with frontal lobe impairment, including ADHD, autism, Tourettes Syndrome, and others. However, the value of project-oriented intervention is not restricted to individuals with such specific neurologic involvement. In fact, most of the points of this rationale apply to most students with disability. SENSE OF SELF AND MOTIVATIONAL THEMES Theme: For adults who (temporarily or permanently) cannot work, manage a family/household, or in other culturally valued ways achieve a sense of productivity and meaningful contribution, engagement in meaningful projects can contribute to a positive sense of self and help to overcome motivational barriers. For children who have difficulty succeeding in traditionally valued school, sports, and recreational activities, engagement in meaningful projects can similarly contribute to a positive sense of self and help to overcome motivational barriers. 1. Sense of Self: Reconstruction of a positive schematic mental model of self as agent (versus patient), contributing worker (versus disabled person), producer (versus consumer), expert (versus handicapped), helper (versus receiver of help), responsible person (versus victim): Frontal lobe impairment: Individuals with acquired neurological impairment need to construct an acceptable sense of personal identity that includes their new profile of abilities and disabilities. Often they fight between two equally unhelpful identities: (1) The helpless, incompetent victim, an identity associated with self-pity, sense of helplessness, and lack of motivation, and (2) the angry Doberman who refuses to recognize limitations created by the injury and fights anybody who defies this identity. Furthermore, in the case of frontal lobe injury (especially right hemisphere ventral, prefrontal), this task is particularly difficult because the part of the brain critically involved in constructing an organized sense of identity is itself injured. Thus individuals need to experience life as agent, contributor, producer, expert, helper who at the same time recognizes the many ways in which life and abilities have changed as part of the process of constructing a positive sense of self. Well designed projects facilitate this process. Children with disabilities: Increasingly the research on children with disabilities has revealed
relatively disorganized sense of personal identity and low self-esteem. Current models of strategy learning and use in special education (e.g. Borkowski) suggest that the impaired learner needs to construct a positive hoped for self as a foundation for integrating effortful strategies into everyday learning routines. 2. Self-Esteem:

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Common sense combined with years of careful research (esp. the work of Martin Seligman) yields the conclusion that positive self-esteem is a bi-product of success with meaningful activities just as low self-esteem is a bi-product of a lack of success with meaningful activities. People with chronic impairment after TBI have difficulty achieving success in their activities, especially success as measured by their own preinjury standards of success. Therefore there is good reason to assist people in their efforts to achieve genuinely successful products of their effort. Children with disabilities: The same rationale applies. 3. Intrinsic motivation: People with acquired disability are often unmotivated to participate in activities that are not directly related to their personal goals. Furthermore, over use of extrinsic motivators that are not naturally related to the activity have been repeatedly shown to reduce internal motivation over time. Thus projects that are intrinsically motivating can play a positive role in rehabilitation. Children with disabilities who are repeatedly rewarded for participation with reinforcers unrelated to the specific purpose of the activity (e.g., stickers, points, tokens) easily grow dependent on such extrinsic motivation and correspondingly lose intrinsic motivation. Thus intrinsically motivating projects can play a positive role in their special education. Egocentrism, brain injury, and frontal lobe function: Frontal lobe impairment often adds to difficulty that people have stepping outside their own perspective, particularly people who lives have been changed by the injury. That is, egocentrism can be both a neurological and psychological phenomenon after TBI. Projects that offer individuals with disability a contributory or helper role can contribute to overcoming this egocentrism. Children with disabilities often have a similar difficulty stepping out of their own perspective and perceiving the world from the perspective of another person (theory of mind). This is particularly true of children on the autism spectrum. Such children may benefit from engagement in a project in which they attempt to help some other people. Oppositionality and personal relevance: Many young people with acquired brain injury were oppositional to some degree before their injury, a characteristic that placed them at risk for injury. Oppositionality may be increased by the injury. In these cases, motivating projects in which the oppositional person is invited to be the expert may help to overcome the oppositionality. Children with disabilities: Oppositionality is also common among children and adolescents with disability, particularly those with a long history of academic and social failure. Well selected and organized projects can play a similar role for these children.

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Internalization of mediated interaction: Self-regulation Unawareness of impairment and/or denial: Bilateral frontal lobe injuries and/or deep right hemisphere lesions are associated with organic unawareness (or reduced awareness) of the impairment. Psychoreactive denial of deficits is a separate phenomenon, but also understandably common among individuals whose lives have been changed by an acquired impairment. Projects offer a positive context in which to learn progressively more about residual strengths and weaknesses.

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More importantly, a project that is specifically about how people with a specific disability can overcome that disability creates a positive context in which to confront the disability. For older children and adolescents with disability, a similar rationale applies. 8. Empty time: Individuals with disability after TBI, particularly adults who are unable to work after their injury, may have large expanses of time in their lives that are empty. Meaningful projects can help to fill otherwise empty hours.

COGNITIVE THEMES Theme: For adults or children who (temporarily or permanently) experience organizational, memory/learning, and elaborative thinking problems, projects can serve as a useful context for either treating these difficulties or circumventing them in pursuing meaningful project objectives. 9. Disorganization, disorientation, managerial knowledge units (MKUs), and frontal lobe function: Individuals with frontal lobe impairment are typically disorganized (to some degree) in their thinking, acting, and talking. A leading explanation for this phenomenon is that the frontal lobes house or organize the application of complex knowledge structures representations of specific event complexes, including managerial knowledge units (MKUs) which are specific event complexes that direct organized social behavior (e.g. social schemas/scripts), organized interaction, and cognitive activity, including remembering, planning, and other forms of organized thinking. Projects can at the same time help organize the life of a disorganized person from day to day and also contribute to the construction of MKUs. Children with disabilities are also often disorganized in their thinking and acting. Projects can serve the same purposes for them. Children who behave in a fragmented, disorganized manner are candidates for projects that help them organize their behavior and lives in general. In addition, children must construct from scratch large numbers of organized knowledge structures (including MKUs) over the course of childhood, mandating mediated organized experiences that go beyond multi-trial drill and practice. Incidental/involuntary learning versus deliberate/effortful learning and frontal lobe function: The frontal lobes are known to be involved in effortful or strategic learning (i.e. the individuals goal is to remember or learn) whereas they are not believed to be involved in involuntary learning (i.e. the individuals goal is internal to the activity (i.e. is NOT to learn) and learning or memory is a bi-product of the deep information processing induced by the activity). Thus for individuals with frontal lobe impairment, engagement in projects with motivating internal goals can be an effective context for embedding to-be-learned information or procedures that then may be processed deeply and remembered via involuntary learning circuits. Children with disabilities: Young children with or without disabilities tend to learn more efficiently with involuntary learning tasks, making them good candidates for project learning. Superiority of involuntary over effortful/strategic memory is a primary feature

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of preschool cognitive development. A wide variety of specific language and preacademic/academic learning objectives can be integrated into work on a project. 11. Elaborative encoding, depth of processing, and frontal lobe function: Frontal lobe impairment: One of the best supported theses about memory is that information that is processed deeply and in an organized, elaborated fashion is more effectively encoded and stored, and more easily retrieved at a later date. The frontal lobes (especially left hemisphere) are believed to be involved in elaborative encoding, particularly when the elaboration must be initiated and organized by the learner. The frontal lobes (particularly right hemisphere) are also involved in retrieval of information that has been encoded and stored in an elaborated manner. Therefore, meaningful projects may be useful for individuals with frontal lobe impairment because the activity itself, ideally combined with expert mediation to enhance the elaboration, creates elaboration that facilitates elaborative encoding and retrieval that would otherwise be difficult for the individual to initiate. Children with disabilities: Like adults, children benefit from elaborative encoding, but need adults to highlight the appropriate elaboration and organization in their experiences. Projects create a context for such highlighting (expert mediation). Situated learning, concrete thinking, transfer of cognitive skill, and frontal lobe function: Individuals with frontal lobe impairment are often characterized as concrete thinkers who experience relatively severe difficulty flexibly transferring new learning from acquisition context to functional application contexts. Therefore, there is a distinct advantage to ensuring that new learning and the practice of skills take place as much as possible in functional application contexts, like meaningful projects. Children with disabilities similarly have difficulty with transfer, arguing for a context-sensitive approach to teaching that projects can provide. Implicit memory, errorless learning, and apprenticeship supports: Severe memory impairment: Individuals with severe explicit memory impairment (associated with hippocampus damage) often have relatively intact implicit memory systems. Explicit memory refers to memories of which the person is to some degree aware. In contrast, implicit memories are retained as traces that influence future behavior and thinking, in the absence of the individuals awareness that such a memory exists. In such cases, errorless learning procedures are recommended in order to avoid the retention of errors that are not recognized as errors. Apprenticeship learning procedures (associated with the project approach) offer the advantage of reducing the likelihood of errors because the master craftsperson in the apprenticeship relationship ensures effective processing of information, correct application of procedures, and a successful outcome. Children with disabilities: The value of errorless learning has also been documented in teaching children with significant disabilities, including mental retardation and other forms of congenital cognitive impairment. Errorless learning is also recommended for individuals who are discouraged as a result of a long history of failure.

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Learning from consequences, routine learning, and frontal lobe function: Individuals with prefrontal damage (particularly damage to ventromedial prefrontal systems) often have relatively severe difficulty learning from the consequences of their behavior. In such cases, traditional teaching and behavior management, relying heavily on performance and feedback (i.e. consequences), may be inefficient. Highly supported learning of routines, relying on antecedent supports as opposed to feedback/consequences, may be preferable in such cases. Children with disabilities: Inefficient learning from consequences is also a characteristic of many children with disabilities (e.g. ADHD, autism), suggesting that highly supported routine learning may be useful for them as well. Cognitive growth as internalization of effectively mediated interaction (Vygotsky): Normal cognitive development: There is evidence that expert verbal mediation, that can occur when a novice collaborates in a meaningful activity with a person who possesses greater expertise, contributes to cognitive growth. Projects offer a useful context for expert mediation, leading to internalization/ appropriation of cognitive and executive function processes.. Children with disabilities: The same rationale applies. Ironically, individuals who are most in need of project-oriented work (for the above reasons) are often denied engagement in projects on grounds (1) that their inability to organize themselves around large activities appears on the surface to mandate the use of very small tasks and (2) that their impairment renders them unable to contribute meaningfully to any project or to be a helper for others. The answer to this dilemma lies in the creative use of collaborative relationships with more competent people, liberal use of prosthetic organizers, and other creative supports that are flexibly provided to enable the person to contribute meaningfully to a project that would very likely be out of reach if performance were solo and unsupported.

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NOTE:

GOALS
1. 2. 3. 4. 5. 6. 7. 8. Initial goals: Focus, motivation, compliance, engagement Cognitive dispositions (e.g. habitually experimental, observant, reflective, analytical, critical) General knowledge structures: MKUs (e.g. planning systems; executive function routine: Goal-Plan-Do-Review) Domain-specific knowledge (knowledge about the projects specific themes, materials, and the like) Emotional dispositions (e.g. motivation to work; persistence; internal motivation; acceptance of responsibility) Organized and positive sense of personal identity (e.g. helper, producer, agent); enhanced self-esteem Language skills Social/communication skills (e.g. conflict resolution; negotiation; anger management;

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ability to communicate respect for others; cooperation; helpfulness) Academic/vocational skills (e.g. reading and writing; math)

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PROCESSES AND PROCEDURES


A. TEACHING ORGANIZING SCHEMES/STRATEGIES: GENERAL (From Ylvisaker, M., Szekeres, S.F., & Haarbauer-Krupa. J. (1998). Cognitive rehabilitation: Organization, memory and language. In M. Ylvisaker (Ed.), Traumatic brain injury rehabilitation: Children and adolescents (Revised Edition)(pp. 181-220). Boston: Butterworth-Heinemann.) GOALS: 1. To help the individual acquire and use organizing schemes to complete complex tasks; 2. If possible, to help the individual understand organizing as a cognitive process and the value of organizational strategies: a. For completing complex tasks b. For remaining focused c. For thinking in an organized manner d. For talking in an organized manner e. For encoding and retrieving information efficiently 3. If possible, to help the individual generalize the strategic use of organizing schemes to other tasks and settings. PROCEDURES: 1. Identify a personally meaningful task that (a) requires some type of organizing activity and (b) has an intrinsic, concrete goal that interests the individual; 2a. Young children or those with significant cognitive impairment: PROCESS THE SCHEME Engage the individual in the task in such a way that he or she must process the organizing scheme in order to complete the task; Highlight the organizing scheme as the activity progresses (if this is not confusing); 2b. Older children and adults with less significant cognitive impairment: METACOGNITIVE REFLECTION Identify why it would be difficult to successfully complete the task without special effort of some sort. Discuss ways in which the task might be completed most easily and effectively (i.e. special procedures, forms, guides, outlines, and the like that might be used); Out of this discussion, select an organizational strategy (e.g. a graphic organizer) that will enable the individual to complete the task effectively; Complete the task, focusing throughout on the importance of the organizational strategy; Invite the individual to evaluate performance with and without the organizing procedure; encourage reflection about the reason for deliberate organizing activity; Identify other tasks for which this or related strategic procedures might be useful; 3. Encourage routine practice with the strategy and generalization to other tasks and settings.

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Gradually reduce external control.

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VYGOTSKYAN VS. TRADITIONAL TRAINING PROCEDURES


Reproduced with permission from M. Ylvisaker and T. Feeney (1998). Collaborative Brain Injury Intervention: Positive Everyday Routines. San Diego, CA: Singular Publishing Group.

TRADITIONAL TRAINING MODEL Context Training takes place outside of a natural setting. Performance of the learner is demanded by the trainer. Performance is solo, not social. Tasks and components of tasks are hierarchically organized. Task structure The trainer requests performance of a specific task. The trainer may model performance. The learner performs. If the performance is adequate, the learner is reinforced. If the performance is inadequate, the trainer either requests a hierarchically easier task; reduces the difficulty of the task; provides needed cues, prompts, shaping procedures. When performance is adequate, repeated practice is required to habituate the learned behavior. Systematic transfer procedures are then applied. VYGOTSKYAN APPRENTICESHIP MODEL Context Learning (ideally) takes place in a natural setting for the behavior or skill that is to be learned. Learning takes place within the context of projects designed to achieve a meaningful goal. Performance is not demanded from the learner; rather the task is completed collaboratively. Completion of the task is social, not solo. The learner is not expected to fail; the collaborator is available to contribute whatever the learner cannot contribute to successful completion of the task. Tasks are not necessarily organized hierarchically; the learner can learn aspects of difficult tasks by participating with a collaborator. Task structure The teacher (facilitator, collaborator) introduces a task and engages the learner in guided observation (not necessarily task specific). The teacher engages the learner in collaborative, functional, goal-oriented,

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project-oriented work. The learner contributes what he or she can contribute. The teacher coaches (including suggestions, modeling, brainstorming, cues, feedback, and encouragement) and continues to collaborate as the learner accomplishes more components of the task. As the learner improves, supports are systematically withdrawn or the task is made more difficult or both. The teacher continues to provide ongoing incidental coaching. Transfer is guaranteed because it is part of the contextualized teaching process from the beginning.

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PROJECT LEADER: RESPONSIBILITIES AND COMPETENCIES


1. Lead as a collaborator (e.g. offer choices, but maintain direction) 2. Ensure that a project is chosen that has the potential to facilitate most of the goals of projects 3. Ensure that all group members have meaningful intervention goals (assuming a group context) 4. Facilitate peer interaction 5. Facilitate peer help and support 6. Provide social and emotional support 7. Offer organizing schemes and other thinking systems as relevant; provide consistent verbal mediation to enhance cognitive processing (elaboration) 8. Ensure ongoing focus on the project and organizing schemes 9. Ensure adequate practice/repetition of targeted cognitive, social, communication, or other skills 10. Facilitate project-related activities and work away from group 11. Create a sense of accountability without anxiety 12. Flexibly integrate a wide variety of goals (e.g. cognitive, social, linguistic, academic, vocational) 13. Focus on skills, competencies, accomplishment, production, contribution 14. Facilitate intrinsic motivation with appropriate coaching and encouragement

CAUTIONS AND CONCERNS


Concern: To Do: Concern: To Do: Concern: To Do: Concern: To Do: Concern: Short lengths of stay in rehabilitation centers interfere with lengthy projects. Design projects that can be completed in a few days Getting started: Its overwhelming! I cant do it!! Start small. Reinforce collaboration concept Getting started: Why should I help others? Im supposed to receive help! Highlight value to the individual; promote culture of mutual support Shouldnt I get paid if I am helping others Highlight intrinsic motivation; possibly consider payment Many people with disability lack cognitive prerequisites for participation in projects. (Staff: The Project failed because he was too impulsive and disorganized) Ensure that appropriate supports are available for people at a lower cognitive level; collaborate!!! you do whatever is necessary to keep the Project going!! Remember, the Project Approach is designed to help people who are impulsive and disorganized so that cannot be an excuse for failure! The Project Approach was originally designed for preschoolers masters of impulsiveness and disorganization.

To Do:

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Concern: To Do:

Transfer of control to the person with disability may be difficult. This should not be a concern; regaining control is a good thing. One of the goals of the project approach is to give the person with brain injury a sense of control, contribution, and mastery. However, some staff and family members have difficulty transferring control. They may assume too many of the project responsibilities, rather than (a) working collaboratively with the person or (b) simply facilitating the persons independent work. Guidance and supervision from a more experienced person may be useful in such cases. People who may insufficiently recognize their limitations should not be invited to think even more highly of their abilities. Facilitation of self-awareness of limitations can be provided in the context of collaborative work (e.g. This is very difficult to do, isnt it? I guess this is an area in which making use of help is a good idea.). People with disability may not be capable of choosing useful projects. The staff person may need to be creative and patient in convincing the person of the value of a project that initially may not be appealing. It may be difficult to generate sufficient numbers of learning trials (massed practice). If one of the goals of the Project Approach is to help the person improve in some specific area of functioning, engagement in a project may appear to yield too few learning trials to be effective. Create systems to distribute large numbers of learning trials across settings throughout the day. Creatively build massed learning trials into the project. (Groups) In rehabilitation settings, lack of consistency in group membership is a concern. Ensure effective orientation for new group members; Ensure that members can benefit regardless of their length of membership in the group (Groups) In rehabilitation settings, diversity in ability levels among group members is a concern. Distribute tasks appropriate to functioning level; have those at a higher level serve as helpers (Groups) In the context of a large project, it is easy to lose focus on the goal of the project and on the rehabilitation objectives that are to be pursued along the way. The group leader must remain vigilant about the focus of the project (use consistent visual reminders and organizers) and about specific rehabilitation objectives. (Groups) Interpersonal conflicts may arise among group members. Use effective seating; remain vigilant

Concern: To Do:

Concern: To Do:

Concern:

To Do:

Concern: To Do:

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Caution: To Do:

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ILLUSTRATIONS OF PROJECTS WE HAVE USED IN BRAIN INJURY REHABILITATION GROUP PROJECTS


Create a staff training video: How to interact with individuals with TBI Create a support video for peers: How to transition successfully from residential program to community living Create a staff training video: How to interact with individuals who use AAC devices Create a staff training video: How to interact with individuals with disability at meal times (or other social times) Create a training video: How to construct a planning system Create a manual for support groups: How individuals with TBI can support their peers Create a manual for family members: How to include a person with disability in everyday planning and problem solving Create a program orientation video: Introduction to our program Create a staff training video: How to facilitate a group Plan and execute outings or other social events Use various housekeeping, maintenance, and office projects in hospital settings

INDIVIDUAL PROJECTS Create a staff training presentation on behavior management after TBI (person with challenging behavior) Create a staff and peer training video: Organizational prosthetics (person with organizational impairment) Create a consumer-friendly manual and video on post-concussion syndrome (person with mild TBI) Create a manual and video for helping adolescents with communication anxiety (person with anxiety disorder) Create a peer training manual (illustrated): How to manage anxiety (person with anxiety disorder) Create a peer training video: How to communicate respect to others and earn the respect of others (person with seriously impaired interpersonal relations and mild paranoia) Create a peer training video: How to make good choices versus acting on impulse (person with severely impaired inhibition) Create a staff training video: How to communicate with and negotiate with this individual Create a self-training video: How to communicate with others Create a self-advocacy video for work supervisor: Supports needed at work (person with peer-related work place problems) Create a self-advocacy video: Presentation of self for potential community support staff (person with volatile relations with support staff) Create a momentum video for self-encouragement (person with years of failure, frustration, and incarceration) Create a manual on overcoming reading problems (adolescent with reading disability) Create a guide to local resources for people with disability Create a guide for developing projects

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Checklist for Evaluating Projects Ensures meaningful participation in meaningful activities Includes producer/expert role for the individual (facilitating a positive sense of self), ensuring opportunities for success Builds self-esteem via success and expert/helper role Linked to interests and abilities Involves meaningful integration of life activities over time (e.g. sessions can begin, Lets see where we are in our project?) Involves some attention to the project throughout the day and across the program (to integrate an otherwise fragmented life and to reduce empty time) Involves meaningful use of practical cognitive prosthetics (e.g. memory book, graphic organizers, photographs, posted reminders, etc.) Involves social interaction (with necessary supports), including conversation, mutual peer help, turn taking, conflict resolution, and the like Supported by a collaborative and elaborative partner interaction style Supported by an apprenticeship approach to learning (with the mentor providing whatever supports are needed for success, and errorless learning procedures if necessary) Includes a predictable format/routine Includes repeated use of executive function routines (e.g. Goal-Plan-Do-Review) Involves deep processing (elaboration) of relevant information Capitalizes on strengths (e.g. implicit learning associated with errorless teaching) (Alzheimers) Capitalizes on preserved long-term memories (Alzheimers) Creates opportunities for reminiscing (Alzheimers) Facilitates awareness of surroundings (people, places, activities/routines) Ideally includes a focus on helping others, with the goal of creating a helper role and facilitating a non-egocentric perspective Enables the individual to become aware of impairments within a generally strength-oriented and success-oriented context Capitalizes on intrinsic motivation (versus artificial extrinsic motivators) Ideally overcomes oppositionality via personal relevance

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Ylvisaker Publications Related to the Project Approach in TBI Rehabilitation


BOOKS Ylvisaker, M. (Ed.)(1998). Traumatic brain injury rehabilitation: Children and adolescents (Revised Edition). Boston: Butterworth-Heinemann. Ylvisaker, M., & Feeney, T. (1998). Collaborative brain injury intervention: Positive everyday routines. San Diego: Singular Publishing Group. CHAPTERS Ylvisaker, M., Szekeres, S., Henry, K., Sullivan, D., & Wheeler, P. (1987). Topics in cognitive rehabilitation. In M. Ylvisaker and E. Gobble (Eds.), Community re-entry for head injured adults (pp. 137-220). Boston: Butterworth-Heinemann. Ylvisaker, M., Szekeres, S.F., & Haarbauer-Krupa. J. (1998). Cognitive rehabilitation: Organization, memory and language. In M. Ylvisaker (Ed.), Traumatic brain injury rehabilitation: Children and adolescents (Revised Edition)(pp. 181-220). Boston: Butterworth-Heinemann. Ylvisaker, M., Chorazy, A., Feeney, T., & Russell, MD (1999). Traumatic brain injury in children and adolescents: Assessment and rehabilitation. In M. Rosenthal, E. Griffith, J. Kreutzer, & B. Pentland (Eds.), Rehabilitation of the adult and child with traumatic brain injury (3rd Edition)(pp. 356-392). Philadelphia: F.A. Davis. Ylvisaker, M., Feeney, J., & Feeney, T. (1999). An everyday approach to long-term rehabilitation after traumatic brain injury. In B. Cornett (Ed.), Clinical practice management in speech-language pathology: Principles and practicalities (pp. 117-162). Gaithersburg, MD: Aspen Publishing Co. Ylvisaker, M., Szekeres, S., & Feeney, T. (2008). Communication disorders associated with traumatic brain injury. In R. Chapey (Ed.), Language intervention strategies in aphasia and related neurogenic communication disorders, 5th Edition (pp. 879-962). Baltimore: Lippincott, Williams and Wilkins. JOURNAL ARTICLES Feeney, T., & Ylvisaker, M. (1995). Choice and routine: Antecedent behavioral interventions for adolescents with severe traumatic brain injury. Journal of Head Trauma Rehabilitation, 10(3), 67-82. Ylvisaker, M., & Feeney, T. (1996). Executive functions: Supported cognition and self-advocacy after traumatic brain injury. Seminars in Speech and Language, 17, 217-232. Ylvisaker, M., & Feeney, T. (2000). Reflections on Dobermans, poodles, and social rehabilitation for difficult-to-serve individuals with TBI. Aphasiology, 14, 407-431. Ylvisaker, M., & Feeney, T. (2000). Construction of identity after traumatic brain injury. Brain Impairment, 1, 12-28. Feeney, T., Ylvisaker, M., Rosen, B., & Greene, P. ( 2001). Community supports for individuals with challenging behavior after brain injury: An analysis of the New York State Behavioral Resource Project. Journal of Head Trauma Rehabilitation, 16(1), 61-75. Ylvisaker, M., Hanks, R., & Johnson-Greene, D. (2002). Perspectives on rehabilitation of individuals with cognitive impairment after brain injury: Rationale for reconsideration of theoretical paradigms. Journal of Head Trauma Rehabilitation, 17(3), 191-209. Ylvisaker, M. (2003). Context-sensitive cognitive rehabilitation: Theory and practice. Brain Impairment, 4(1), 1-16. Ylvisaker, M. (2006). Self-coaching: A context-sensitive approach to social communication after traumatic brain injury. Brain Impairment, 7, 246-258. Ylvisaker, M., Feeney, T., & Capo, M. (2007). Long-term community supports for individuals with co-occurring disabilities: Cost effectiveness and project-based intervention. Brain Impairment, 8(2), 1-17.

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SUPPORTIVE INTERACTION STYLE: COLLABORATION AND ELABORATION


Modified with permission from Ylvisaker, M., Sellars, C., & Edelman, L. (1998). Rehabilitation after traumatic brain injury in preschoolers. In M. Ylvisaker (Ed.), Traumatic brain injury rehabilitation: Children and adolescents (Revised Edition)(pp. 303-329). Boston: Butterworth-Heinemann.

COLLABORATION PROCEDURES

Implicit Message: "We are doing this together as a cooperative project"


Supportive Collaborative Style Collaborative Intent
Shares information Uses collaborative talk (e.g., Lets think about this) Communicates understanding of partner's contribution Invites partner to evaluate own contribution Confirms partner's contributions Shows enthusiasm for partner's contributions Makes effort to establish equal leadership roles

Noncollaborative Style Noncollaborative (e.g., Teaching, Testing) Intent


Demands information Talks as teacher or trainer Fails to communicate understanding of partner's contribution Fails to invite partner to evaluate own contribution Fails to confirm partners contribution Expresses lack of enthusiasm Takes leadership role, despite other's attempt to contribute

Cognitive Support
Gives information when needed (within statements or questions) Makes available memory and organization supports (e.g., calendar, photos, memory book, gestures) Gives cues in a conversational manner Responds to errors by giving correct information in a nonthreatening, nonpunitive manner. Communicates respects for other's concerns, perspectives and abilities Explicitly acknowledges difficulty of the task (e.g. "It's hard to put all these things in order, isn't it?")

Lack of Cognitive Support


Does not give information when needed; continues to quiz Fails to use cognitive supports at appropriate times Fails to give necessary cues Corrects errors in a punishing manner.

Emotional Support

Lack of Emotional Support


Fails to communicate respect for others concerns, perspectives, and abilities Fails to acknowledge difficulty of the task

Questions: Positive Style


Questions in a nondemanding manner Questions in a supportive manner (e.g., questions include needed cues: Do you need a wake-up call in the morning?) Takes appropriate conversational turns Helps partner express thoughts when struggle occurs (e.g. word finding difficulties)

Questions: Negative Style


Questions in a demanding manner (i.e., performance-oriented quizzing) Questions in a nonsupportive manner (e.g., questions lack needed cues: e.g., How are you going to get that done?)

Collaborative Turn-taking

Noncollaborative Turn-taking
Interrupts in a way that disrupts partners thought process and statements Fails to help partner when struggle occurs

Ylvisaker Handout: Project Approach Page 20

ELABORATION PROCEDURES Implicit Message: "I am going to help you organize and extend your thinking" Positive Elaborative style Nonelaborative style Elaboration of Topics
Introduces/initiates topics of interest with potential for elaboration . Maintains topic for many turns Contributes many pieces of information to topic Invites elaboration (e.g., "I wonder what happened..."). Conversationally organizes information as clearly as possible: sequential order of events (e.g., First we..., then we...") physical causality (e.g. "The radios not working because it got wet.") psychological causality (e.g., "Maybe youre avoiding it because youre scared.) similarity & difference (e.g., "Yes, theyre similar because...") analogy & association (e.g., "That reminds me of... because...) Reviews organization of information Makes connections when topics change Makes connections among day to day conversational themes .

Nonelaboration of Topics
Introduces topics of marginal interest, with little potential for elaboration Changes topic frequently Fails to add adequate information to topic Fails to invite other to add information

Elaborative Organization

Nonelaborative Organization
Fails to organize information

Fails to review organization of information Fails to make connections explicit when topics change. Fails to make connections among day to day conversational themes. Meaning is vague.

Elaborative Explanation
Conversationally adds explanation for events (e.g., "Maybe the fact that you were drunk at the time had something to do with it.") Invites explanations for events Invites discussion of problems and solutions (e.g., "I wonder whether we can think of a better way to handle this if it comes up again."); invites partner to address problems and solutions. Reflects on others physical and psychological status (e.g., "You must have felt miserable about that) and invites other to reflect on his/her physical and psychological states.

Nonelaborative Explanation
Offers few explanations Fails to invite explanations Does little problem solving or all of the problem solving; fails to invite partner to address problems and solutions Fails to reflect on or invite the other to reflect on other's physical or psychological status