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Integrated Behavioral Intervention and Person-Centered Therapy Within Community-Based Treatment of an Adult With Acquired Brain Injury

Joseph N. Ricciardi1, Sonya Woelfel Bouchard1, James K. Luiselli2 , and Trudy Dould1

Abstract We present the case of a 30-year-old woman who had acquired brain injury (ABI) and demonstrated clinically challenging behaviors (verbally abusive outbursts toward care providers and elopement) within her community-based group home. Following a baseline phase of evaluation, she collaborated with clinicians and care providers in developing a treatment plan that included personal goal setting, differential token reinforcement, communication training, graphic performance feedback, and reinforcement fading. During 10 months of intervention, clinically challenging behaviors steadily decreased from baseline levels and low-frequency occurrence was maintained at 3-, 6-, and 9-month follow-up assessments. As the result of treatment, the woman also avoided prior psychiatric hospitalizations, enjoyed more frequent access to pleasurable activities outside her residence, and enrolled in a college course. The study illustrates an effective person-centered therapy approach combined with behavioral intervention for persons who have ABI and experience community-living adjustment difficulties.

Keywords acquired brain injury, applied behavior analysis, behavioral neurorehabilitation, person-centered therapy, traumatic brain injury

1 Theoretical and Research Basis for Treatment

Acquired brain injury (ABI) is brain damage to a person after birth caused by internal sources such as stroke, encephalopathy, and tumors (Kolakowsky-Hayner et al., 2016). Traumatic brain injury (TBI) is a type of ABI from external events, for example, falls, motor vehicle accidents, blunt force from an object or weapon, and neurosurgery (Faul et al., 2010). It is estimated that 2.5 million children and adults sustain a TBI each year (Brain Injury Associate of America: www. biausa.org). The common sequelae from ABI include emotional dysregulation, affect lability,

1Seven Hills Foundation, Worcester, MA, USA 2Melmark New England, Andover, MA, USA

Corresponding Author: Joseph N. Ricciardi, Assistant Vice President/Director of Clinical Services, Seven Hills NeuroCare, Seven Hills Foundation, 81 Hope Avenue, Worcester, MA 01603, USA. Email: [email protected]

890925CCSXXX10.1177/1534650119890925Clinical Case StudiesRicciardi et al. research-article2019

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disinhibition, irritability, and externalizing behaviors in the form of aggression, environmental disruption, and property destruction (Arciniegas & Wortzel, 2014; Simpson et al., 2014). These impairments can be long-standing, extending many years after injury, despite comprehensive rehabilitation and neurobehavioral intervention (Alderman & Wood, 2013; Geurtsen et al., 2010; Ponsford et al., 2014). Notably, persons with ABI often experience numerous placement failures, living restrictions, and limited community reintegration (Kolakowsky-Hayner et al., 2016). As well, the effects of TBI frequently place an individual at risk for self-harm, offending behavior, and social stigmatization (Arciniegas & Wortzel, 2014).

Several reviews have summarized the outcomes from applied behavior analysis (ABA) inter- ventions with persons who have TBI and problems with emotional control, impulsivity, irregular mood, and aggression. Ylvisaker et al. (2007) identified 65 studies in which three categories of behavioral intervention had been implemented: (a) contingency management procedures com- mon to ABA, (b) methods generally associated with positive behavior intervention and support (PBIS), and (c) programs “with a relatively balanced combination of ABA and PBIS” (p. 771). The most effective ABA procedures demonstrated in the studies were differential positive rein- forcement, negative reinforcement, extinction, and mild punishment (e.g., response cost). Effective PBIS procedures included establishing meaningful activity routines, antecedent control strategies, choice making, and communication training. The primary service settings supporting behavioral intervention were acute and post-acute rehabilitation facilities, schools, homes, and community-based programs. In addition, the authors applied review and rating standards of the American Academy of Neurology (Edlund et al., 2004) and concluded that for people with brain injury, behavioral intervention for challenging behavior was a “practice guideline” (a recommen- dation that reflects moderate clinical certainty) as was the use of functional behavior assessment (FBA) in intervention design. Furthermore, the specific behavioral interventions grouped under contingency-based management and PBIS should be considered “evidence-based treatments.”

In a related review, Heinicke and Carr (2014) conducted a meta-analysis of ABA single-case design (SCD) intervention research with persons receiving ABI rehabilitation (ABI = injuries resulting from internal and external insults). Among 112 identified studies, 60% focused on inter- ventions to reduce behaviors such as inappropriate vocalizations, aggression, and environmental disruption. Another 38% of the studies addressed instructional methods for improving academic and social skills. The most common methods of behavior reduction were differential reinforce- ment and antecedent control, while self-management and reinforcement were implemented most frequently for skill acquisition. According to the evidence-based practice criteria defined by the American Psychological Association (APA) Division 12 Task Force (Chambless & Ollendick, 2001), Heinicke and Carr (2014) concluded that reinforcement and antecedent variables (skill acquisition) and differential reinforcement, antecedent intervention, and punishment (behavior reduction) could be classified as “well established.”

Among many factors to consider when designing behavioral interventions for persons with ABI, Ylvisaker et al. (2007) and Heinicke and Carr (2014) suggested that different combinations of procedures are possible and may be warranted to produce the most robust treatment effect. Second, ABA research has shown that functional behavioral assessment (FBA) should be per- formed to inform procedures that are linked to the conditions that evoke and maintain problem responses (Call et al., 2017; Field et al., 2004). Specifically, “Functional behavior assessments and ongoing monitoring of the individual’s response to intervention are particularly critical in behavioral rehabilitation” (Ylvisaker et al., 2007, p. 783). Finally, whenever possible, behavioral intervention targeting individuals with brain injury can benefit from a person-centered therapeu- tic approach which considers integration of self-identified preferences, self-determination, and collaborative problem solving (Cattelani et al., 2010; Shogren et al., 2017).

This case report describes treatment of an adult who had ABI and demonstrated unsafe and clinically challenging behaviors within her community-based residence setting. Intervention

Ricciardi et al. 135

planning followed FBA and recognition of the woman’s personal motivations to select, achieve, and evaluate treatment objectives leading to greater independence and improved quality of life. The case illustrates a model of behavioral intervention derived from ABA and combined with person-centered therapy within a framework of contemporary neurorehabilitation (Heinicke & Carr, 2014; Ylvisaker et al., 2007).

2 Case Introduction

Natalie was a 30-year-old woman who suffered an ABI 12 years preceding the treatment described in this case study. She lived in a community-based group home for individuals with acquired brain injuries and received individualized (1:1) support from care providers throughout her awake hours. The care providers implemented instructional and training procedures with Natalie according to a neurofunctional rehabilitative model that focused on self-care, daily living, voca- tional, and safety skills (Clark-Wilson et al., 2014).

Natalie carried a diagnosis of major neurocognitive disorder due to another medical condition (pineal tumor) and with behavioral disturbance (Diagnostic and Statistical Manual of Mental Disorders; 5th ed.; DSM-5; American Psychiatric Association, 2013, 294.11; International Classification of Diseases, Tenth Revision; ICD-10, F02.81; World Health Organization, 2018). Her record referenced numerous previous psychiatric conditions and diagnoses, including para- noid state, paranoid personality disorder, and obsessive-compulsive disorder. Overall, her domi- nant psychiatric presentation was transient states of anxiety and dysphoria (sadness and anger) with paranoid ideas of being harmed by caregivers. Most concerning was a severe behavior dis- order characterized by outbursts of yelling and profanity, threats of harming herself and others, and eloping from care settings. At the time of this treatment, she was taking olanzapine (5 mg), divalproex sodium (1,250 mg QHS), flovoxamine (100 mg), and melatonin (1 mg) daily.

3 Presenting Complaints

The concerns that prompted referral for treatment were Natalie demonstrating loud and volatile verbal outbursts and eloping from her group home. During outbursts, she yelled at and made profane statements toward care providers and other residents using a threatening tone and with accompanying motor agitation and emotional distress. These verbal outbursts were disruptive, antagonistic, and socially intrusive. In addition, Natalie would exit the group home and if not interrupted, leave the property, placing her at great risk along roadsides or possibly entering a neighbor’s house. Although attempts to stop her from eloping were successful some of the time, she typically resisted interference from care providers and continued to move from the group home boundaries while care providers trailed behind and attempted to contain her. On several occasions, she exited the group home unseen, was discovered missing, and required a neighbor- hood search until she was found. These challenging behaviors were long-standing, had been exhibited in her family home and a nursing facility, and necessitated restrictive protocols to maintain safety (e.g., locked doors, exit alarms).

4 History

Natalie was diagnosed with a benign pineal papilloma when she was 16 years old, received radia- tion and resection, but the tumor compressed the cerebral aqueduct resulting in obstructive hydrocephalus requiring external shunting and lumbar drain procedures. Over the next several years, tumor regrowth and recurrent hydrocephalus led to multiple surgical procedures including repeated draining of cerebrospinal fluid accumulation, implantation of a ventriculoperitoneal shunt, and several shunt revisions causing slit ventricles. Eventually, she suffered a fall that

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produced a second head injury and severe left sided hygroma needing surgical implantation of a new shunt. A magnetic resonance imaging (MRI) revealed a secondary finding of lacunar infarct, left thalamus. Despite at least 12 surgical procedures, her condition and functional status contin- ued to decline.

As her neuropsychological and skill deficits accumulated, Natalie experienced problems with memory, planning, inhibition of impulses, and judgment. She showed oculomotor anomalies, abnormal gait, dysarthria, tremors, and muscle weakness, making it difficult for her to complete most activities of daily living without some level of support from care providers. During this period, her mental status deteriorated with accompanying emotional dysregulation, paranoia, and impulsive and sometimes dangerous behaviors such as threatening suicide, attempting to leap from a second story window, calling 911 for help, and leaving her family home.

After several psychiatric hospitalizations with discharge to family, Natalie was eventually transferred to a secure skilled nursing facility where she remained for 18 months. She was sub- sequently admitted to the community-based residential group home where the present study was conducted.

5 Assessment

Neuropsychological, functional skills, and behavioral assessments were conducted with Natalie preceding treatment. The Mayo-Portland Adaptive Inventory, 4th Edition (MPAI-4) (Malec, 2005; Malec et al., 2003) revealed a total MPAI raw score of 61 (T-score = 54) and the following raw scores on MPAI subscales: Ability Scale, 23 (T = 54), Adjustment Scale, 23 (T = 53), and Participation Scale, 24 (T = 55). All scores were indicative of moderate to severe limitations compared with national sample of people with ABI receiving services in community-based resi- dential rehabilitation facilities. The Overt Behavior Scale (OBS; Kelly et al., 2019) revealed 13 distinct and clinically significant challenging behaviors within the categories of verbal aggres- sion, physical aggression against objects, physical aggression against others, perseveration/repet- itive behavior, wandering/absconding, inappropriate social behavior, and lack of initiation. The clinical rating of distress and disruption created by these behaviors ranged from “minor” to “extreme.” In summary, clinical assessment identified Natalie as a person with brain injury of moderate to severe limitations, complicated by multiple topographies of challenging behaviors that caused a moderate impact in her adjustment in community living.

The authors also conducted FBA comprising interviews with care providers, daily recording forms, and antecedent-behavior-consequence measures from direct observations of Natalie in the group home (Rahman et al., 2013). These FBA findings were reviewed by clinicians and pre- sented to care providers for clarification and refinement. Key results suggested that the challeng- ing behaviors Natalie demonstrated usually produced attention from care providers in the form of emotional support and helping her identify acceptable alternative activities. Ancillary observa- tions supported a socially mediated reinforcement formulation wherein challenging behaviors were more likely to occur when Natalie was bored, isolated, and unengaged. However, she had poor self-initiation and was dependent on others to prompt participation in daily routines. Furthermore, she often misperceived and negatively evaluated peer and care provider intentions (poor social judgment), also evoking challenging behaviors.

Third, informal preference assessment suggested that Natalie responded well to social support and feedback from care providers with whom she had a positive relationship. She was also less likely to exhibit challenging behaviors when paired with care providers who spoke with her fre- quently, shared experiences, and provided rich social engagement during daily activities.

During baseline and intervention phases (described below), care providers performed direct assessment by recording three target behaviors each day: (a) verbal outburst (an episode of Natalie yelling, swearing, and making hostile statements toward peers and care providers), (b)

Ricciardi et al. 137

attempted elopement (an episode of Natalie trying to or actually exiting the group home but not leaving the property), and (c) elopement from property (an episode of Natalie both exiting the group home and leaving the property). Single episodes were recorded by care providers on a daily data tracking form when Natalie ceased engaging in the target behaviors for five continuous minutes.

6 Case Conceptualization

Natalie’s challenging behaviors were conceptualized as learned operant responses in the context of severe neuropsychological impairments (Wood & Worthington, 2017). She was socially moti- vated, sought interpersonal engagement with care providers, desired to please her family, and tried to repair relationships after challenging behaviors occurred. The challenging behaviors Natalie demonstrated created an immediate risk to her well-being and always required immediate supportive consequences from care providers which we hypothesized functioned as adventitious social reinforcement of maladaptive responses typically observed in people with a dysexecutive syndrome (Arciniegas & Wortzel, 2014).

Accordingly, our treatment approach was explained to Natalie as a plan for increasing her self-control by “rewarding” brief periods of time she did not demonstrate challenging behaviors. A senior clinician (second author) discussed that developing self-control would improve her social relationships, maintain personal safety, and help achieve high-priority life goals of visiting regularly with her family, returning to college, and becoming a nurse. As well, treatment was conceptualized with an emphasis on Natalie’s social responsiveness to preferred persons, motiva- tion to improve quality of life, and ability to understand and contribute to intervention planning and implementation. This person-centered therapy approach (Hayes & Burford, 2018; Tursi & Cochran, 2006), combined with behavioral intervention, was intended to focus on (a) her affinity for positive regard and affirmation from helping professionals, (b) social support that enabled her to define and clarify personal goals, and (c) taking steps to achieve greater independence (Castro et al., 2016).

7 Course of Treatment and Assessment of Progress

During the baseline phase (3 months), care providers monitored and recorded verbal outburst, inter- rupted elopement, and elopement from property episodes while delivering episode-contingent de- escalation cues (Lennox et al., 2011). For example, if Natalie appeared agitated, displayed a verbal outburst, or attempted to elope from the group home, care providers would inquire, “What’s going on, Natalie, can I help you?” Care providers then prompted her to perform adaptive behaviors such as returning to the group home to discuss concerns or transitioning to another location within the group home to review problem-solving alternatives. If Natalie did not respond compliantly and her agitation continued, care providers paused, remained silent, monitored safety, and repeated helping suggestions. These procedures were in effect before the study and continued during formal baseline conditions.

The treatment phase (10 months) immediately followed baseline assessment and incorporated three primary components. First, care providers were trained to implement differential reinforce- ment of other behavior (DRO; Woodhead & Edelstein, 2008) by placing a check mark on a tally sheet following 1-hr daily intervals in which Natalie did not display a verbal outburst, interrupted elopement, and elopement from property episode. Presentation of check marks was accompanied by care provider praise and approval. After receiving a criterion number of check marks, Natalie was given a preselected gift card she could redeem for edible treats (e.g., ice cream, hot choco- late) and tangible items such as nail polish, cosmetic products, and jewelry. Within this token reinforcement protocol, the first DRO criterion was eight check marks (1 hr-DRO 8), followed

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by 40 check marks (1 hr-DRO 40) and finally 80 check marks (1 hr-DRO 80). The hourly interval was reset by care providers when Natalie demonstrated a verbal outburst, attempted elopement, or elopement from property episode. In illustration, if a verbal outburst was encountered 30 min into an hourly interval, care providers would reset the interval to 1 hr after Natalie was fully composed for 5 min and they explained to her that she should remember to practice being “calm and safe.” These DRO criterion changes were made based on suggestions from Natalie about alternative reinforcers, discussed below, and clinician interpretation of the verbal outburst, attempted elopement, and elopement from property frequency data.

The second component of treatment was person-centered therapy that encouraged Natalie to have an active role in reviewing procedures and progress through discussions with her clinician and care providers. This collaboration allowed Natalie to self-determine the direction of her treat- ment plan and select goal-setting objectives. For example, Natalie proposed the previously refer- enced DRO criterion changes to her clinician while reviewing the behavior data and suggesting she could “work harder” to earn other gift cards of greater value. In addition, clinician guided self-evaluation, data review, and supportive decision making with Natalie was consistent with the goals of cognitive rehabilitation which emphasize strategic planning opportunities and valued social engagement (Haskins et al., 2012).

Finally, care providers prompted Natalie to perform alternative behaviors that were intended as functionally equivalent to verbal outbursts and elopement. They would offer suggestions such as “If you are bored, let me know and we can do something,” and “If you think you want to run from the house, speak to me so we can discuss what’s going on.” The emphasis during treatment was care providers delivering such prompts periodically during the day when Natalie appeared responsive to their verbal exchanges and not following the display of challenging behaviors. However, to maintain safety, care providers continued to interrupt and redirect Natalie from elopement as implemented during the baseline phase.

Throughout treatment, the director and assistant director of the group home monitored proce- dural implementation and data recording by care providers daily. The senior clinician also observed care providers interacting with Natalie, met with them biweekly to review components, application, and effects of the treatment plan, and conducted training through further task clarifi- cation, modeling, and in vivo performance feedback on some occasions (Parsons et al., 2012).

Figure 1 presents the average daily frequency of verbal outburst, interrupted elopement, and elopement from property episodes each month. During the baseline phase, Natalie displayed 1.3 to 3.1 verbal outburst episodes per day (M = 1.97), 0.5 to 0.7 interrupted elopement episodes per day (M = 0.59), and no episodes of elopement from property. An increasing trend was evident for verbal outburst episodes and a slight decreasing trend was documented for interrupted elope- ment episodes.

The first treatment phase (1 hr-DRO-8) lasted 4 months and was associated with 1.2 to 2.3 verbal outburst episodes per day (M = 1.68), 0.4 to 0.9 interrupted elopement episodes per day (M = 0.62), and nine episodes of elopement from property. In the second treatment phase (1 hr- DRO-40) lasting 3 months, Natalie displayed 1.35 to 2.51 verbal outburst episodes per day (M = 1.97), 0.64 to 1.06 interrupted elopement episodes per day (M = 0.86), and no occurrences of elopement from property episodes. During the third treatment phase (1 hr-DRO 80) lasting 3 months, there were 0.38 to 1.57 verbal outburst episodes per day (M = 1.06), 0.23 to 0.86 inter- rupted elopement episodes per day (M = 0.62), and no occurrences of elopement from property episodes.

In summary, the most immediate intervention effect with Natalie was the variable and gradual decrease in verbal outburst episodes across the three DRO treatment phases. Episodes of inter- rupted elopement increased slightly from baseline levels during Phase 1 DRO and Phase 2 DRO phases but declined in the final phase. With exception of the second month of treatment, Natalie did not elope from property during the study.

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8 Complicating Factors

Natalie voluntarily collaborated with her clinician during all phases of the study. Changes in care providers affected treatment due to variability in procedural integrity occasionally observed when novel individuals began in the group home. Indeed, a significant portion of variability dur- ing phase 1 of treatment appeared to be the result of increased turnover among care providers. At times, scheduling medical appointments, illnesses, and holidays also intruded on continuity of care. Despite these complications, Natalie developed a strong bond with her clinician, group directors, and many care providers, which may have facilitated her compliance and engagement with person-centered therapy throughout treatment. She also did not engage in novel or unantici- pated challenging behaviors or express dissatisfaction with her treatment plan.

9 Access and Barriers to Care

The financial support for Natalie’s community-based residential setting was through government insurance within a Medicaid waiver program for persons with ABI. There were no problems with funding her care and treatment during the course of the study.

10 Follow-Up

We continued to monitor and record verbal outbursts, interrupted elopement, and elopement from property episodes 9 months following the study. As shown in Figure 1, the follow-up results (aggregated in 3-month periods) were 0.42 to 0.52 verbal outbursts per day (M = 0.47), 0.05 to 0.22 interrupted elopement per day (M = 0.12), and no occurrences of elopement from property. These reductions remained relatively stable throughout follow-up. It should be noted that with stability in personal safety and self-control of verbal behavior, Natalie enjoyed increased com- munity access and had enrolled in a college course to prepare for more advanced studies in nursing.

11 Treatment Implications of the Case

Preceding the treatment implemented in this case study, Natalie was confined to a secure psychi- atric facility due to her explosive interactions and dangerous episodes of elopement with parents and care providers. Our community-based treatment prevented further psychiatric crises, effec- tively reduced challenging behaviors, and enabled Natalie to be served in the least restrictive setting where she enjoyed life in a home-style residence, participated successfully with rehabili- tative therapies, and was able to visit with her family more frequently. Several treatment implica- tions, discussed below, are pertinent to her case.

First, behavioral intervention implemented with Natalie emphasized her active participation with planning, goal setting, and evaluation. She collaborated with her clinician in selecting target behaviors and establishing a treatment plan that focused on self-control and communicating more efficiently with care providers to resolve conflicts successfully. Natalie also chose the tangible items she received through DRO and the gradual increase in tokens required to access reinforce- ment. We propose that this person-centered approach encourages and supports an individual with ABI toward treatment selection and is desirable for maximizing motivation, strengthening self- determination, and achieving socially valid outcomes.

Our results further support “well established” ABA procedures for treating challenging behav- iors demonstrated by persons with brain injury, namely differential reinforcement and preven- tion-focused antecedent strategies (Heinicke & Carr, 2014). Ylvisaker et al. (2007) also recommended several treatment procedures that were implemented with Natalie such as choice

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making, engagement with meaningful activities, and “proactive development of positive com- munication alternatives to negative behavior” (p. 778). It is reasonable to conclude that the com- bination of skill building, self-control, and contingency management (reinforcement and extinction) procedures represent comprehensive behavioral intervention for many persons with ABI who experience adjustment and social-communication difficulties within neurorehabilita- tion settings.

This case shows that behavioral intervention in ABI may require a lengthy period of imple- mentation. Several months elapsed before Natalie demonstrated gradual reduction in verbal out- bursts and interrupted elopement, eventually stabilizing at low frequency at follow-up. Most significant during the course of treatment was Natalie’s continued progress while the DRO schedule was gradually faded with her cooperation in an effort to promote therapeutic gains long- term (Cooper et al., 2007).

However, beyond clinician and group home director observations of care providers, we did not conduct formal assessment of treatment integrity (Sanetti & Kratochwill, 2014) or interrater agreement of target behavior data recording. Similarly, the implications of this treatment approach with similar adults who have ABI would be clearer if we had objectively assessed social validity (Snodgrass et al., 2018) by asking Natalie and care providers to rate their satisfaction with and acceptability of the services received and procedures implemented, respectively (Flood & Luiselli, 2016). We reiterate, though, that Natalie’s full cooperation with and commitment to her treatment plan was a valid indication of her acceptance and approval.

12 Recommendations to Clinicians and Students

Clinicians and students are encouraged to conduct FBA before intervening with a person who has ABI (Call et al., 2017; Rahman et al., 2013). In the present case, FBA with Natalie included direct observations and interviews with care providers to isolate the conditions and situations that con- sistently preceded and followed challenging behaviors. Absent such information, practitioners are subject to implementing intervention procedures arbitrarily without clearly identifying behavior-function and forming hypotheses about behavior–environmental relationships. We rec- ommend that clinicians and students consider multiple indirect and descriptive methods when planning and implementing FBA (Iwata et al., 2013; Rahman et al., 2013).

The supervising clinicians with Natalie also consulted with care providers about the proce- dures comprising behavioral intervention and emphasis on personal goal setting and self-man- agement. The care providers were responsible for supporting intervention within the residence setting, encouraging Natalie to communicate with them, responding consistently to challenging behaviors, and delivering reinforcement according to the daily DRO interval schedule. Another recommendation to clinicians and students, referenced previously, is that whenever possible, treatment integrity should be assessed to measure the degree of procedural fidelity among care providers. Our informal observations suggested that the care providers interacting with Natalie complied responsibly to her treatment plan but more direct verification would have confirmed conclusions about intervention success.

As a data-based case study targeting three challenging behaviors, continuous measurement was in place to monitor Natalie’s reaction to treatment. Within the baseline phase, each challeng- ing behavior occurred at moderately high (verbal outburst), relatively low (interrupted elope- ment), and zero (elopement from property) frequencies. We recommend such tracking of multiple behaviors to detect co-variation and different response trends possibly evident during treatment. That is, treatment might reduce some but not all challenging behaviors, making it necessary to introduce alternative procedures. Case study behavior data of the type recorded with Natalie do not demonstrate experimental control (Kazdin, 2011) but are invaluable on a clinical level for justifying treatment decisions in the best interest of the client.

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Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical stan- dards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

James K. Luiselli https://orcid.org/0000-0001-6989-9155

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Author Biographies

Joseph N. Ricciardi is director of Clinical Services and assistant vice president at Seven Hills NeuroCare, and Seven Hills Foundation, Worcester, Massachusetts.

Sonya Woelfel Bouchard is an acquired brain injury clinician at Seven Hills NeuroCare, Worcester, Massachusetts.

James K. Luiselli is director of Clinical Development and Research at Melmark New England, Andover, Massachusetts, and adjunct faculty in the Department of School Psychology, William James College, Newton, Massachusetts.

Trudy Dould is an acquired brain injury clinician and certified rehabilitation counselor at Seven Hills NeuroCare, Worcester, Massachusetts.