Back to School—With a TBI New campus programs spearheaded by speech-language pathologists aim to help students get their academics back on track. Features
Features  |   December 01, 2015
Back to School—With a TBI
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School-Based Settings / Professional Issues & Training / Attention, Memory & Executive Functions / Traumatic Brain Injury / Features
Features   |   December 01, 2015
Back to School—With a TBI
The ASHA Leader, December 2015, Vol. 20, 46-50. doi:10.1044/leader.FTR2.20122015.46
The ASHA Leader, December 2015, Vol. 20, 46-50. doi:10.1044/leader.FTR2.20122015.46
When she received her bachelor’s degree in mathematics in spring 2015, Kacie Carlsted may have seemed like many other newly minted graduates. Except she wasn’t.
Seven years earlier, on the brink of giving the valedictory speech at her high school graduation, Carlsted was in a car accident that left her hospitalized for months with multiple injuries, including a fractured pelvis, punctured lung, liver lacerations and traumatic brain injury (TBI). This was days before she was slated to graduate and enter Augsburg College, near her home in Minnesota.
A year later—after physical and occupational therapy and speech-language treatment helped Carlsted to walk and talk again—she instead enrolled at a different college about an hour from her home in Howard Lake, Minnesota. But she withdrew weeks into the first semester.
Carlsted felt overwhelmed by a full course load, which included courses that required a lot of memorization and focus—calculus and biology, for example. “I didn’t know that I couldn’t handle those classes. I believed I was the same as I was before the accident,” she says. “And when I realized this, it was too late to drop or switch classes.”
Before withdrawing, she had been receiving cognitive coaching from Mary R. Kennedy, then an associate professor in the Speech-Language-Hearing Sciences Department at the University of Minnesota-Twin Cities. “Dr. Kennedy did not persuade me to withdraw, but I’m sure she helped me realize that either choice was okay. She helped calm the 4.0 student perfectionist in me,” says Carlsted.
Kennedy, now a professor in the Communication Sciences and Disorders Program at Chapman University in Orange, California, had recently established a campus program for students with TBI. She had spent years as a speech-language pathologist, working with people with brain injury and researching metacognition and self-regulation: How do people understand their own thought processes, and how do they set goals and make plans to achieve those goals?
Seeing a need
The campus program “seemed like a natural application of what I’d been researching,” Kennedy says. “Come up with an approach to provide support while students were on campus to help them figure out … what they needed and what they didn’t need.”
She developed a survey for students with TBI. In general, the students described four areas of challenge: time management and organization, learning and studying, social relationships, and anxiety.
“We tried to then develop some support,” says Kennedy, by meeting with each student once a week. “We figured if we worked on the first three issues, the anxiety piece would improve.”
Ultimately, Kennedy established the University of Minnesota (UM) College Program for Students with Brain Injury, which uses dynamic, interactive coaching. Students like Carlsted receive support based on their neuropsychological strengths and weaknesses, as well as their preferences and academic interests. The coaches are SLPs with expertise in working with people after brain injury.
Setting goals
With coaches, students in the UM program identify goals in several areas:
  • Self-learning, such as “I want to get a B in this class” or “I want to write better papers.”

  • Self-management, such as “I want to turn in all of my assignments on time” or “I want to write papers gradually, rather than waiting until the last minute.”

  • Self-advocacy, such as “I want to discuss my brain injury with my professors” or “I want to find ways to spend more time with friends.”

The coaches use best-practice principles from cognitive-rehabilitation therapy as the students learn strategies to meet their goals, use the strategies and assess how well they work.
“If students can figure out what they can still do and what they can’t do anymore, and then come up with strategies to compensate, their chances of succeeding increase,” Kennedy says. “We’re trying to have the students become their own experts in how they think and communicate, because the last thing they want is to keep coming back to us for therapy. These are patterns of thinking they can use the rest of their lives.”
Kennedy’s tips for coaching students include being an active listener, considering a student’s readiness to change, being flexible, acknowledging costs and benefits, and knowing when to refer students to other professionals.
She says that with coaching, students see near-immediate changes in grades and in outlook, and many become more social. “I think the support of an SLP coach gives them another person who can validate what they are going through,” she says. “It allows them to launch from there and take more risks.”
Carlsted agrees. “My meetings with Dr. Kennedy were meant for coaching and helping me with strategies in my classes,” she says. “I also think meeting with her helped me get my head out of my books and actually have fun in college … It meant so much more for me, though. I had someone to talk to who understood me.”
The Department of Defense is using Kennedy’s coaching approach as the foundation for a cognitive toolkit on mild TBI in veterans who enroll in college. Kennedy also worked with the defense officials on a manual for veterans with TBI who want to go back to college. (She collaborated on a webinar and is working on a book with Don McLennan of the Minneapolis VA Health Care System, who runs a program there to prepare veterans with TBI for college.)
At the University of Wisconsin-Madison, Lyn Turkstra, a professor in the Department of Communication Sciences and Disorders, has also led the way in developing systems to help students with TBI. Her priority is getting students with moderate-to-severe TBI qualified to receive accommodations and services through the university’s disability resource center.
“Once the student is eligible under the [Americans With Disabilities Act], everything is easier,” she says. “Getting qualified can be daunting, so sometimes our first meeting with a student is helping them figure out how to apply.”
Turkstra and other SLPs focus on classroom environment. An SLP will sit in class with the student and observe. How fast is the pace? How structured is it? Are there lecture outlines? Is there a lot of group work? What’s the instructor like? “The instructor is the biggest factor,” she says. “If they are not clear in the way that they lecture, or if they talk fast, that can cause problems.”
Severe brain injuries, such as Carlsted’s, make up only about 25 percent of all brain injuries, according to the Brain Injury Association, with mild brain injuries and concussions making up the majority. And while recovery from a mild brain injury may take only weeks to months, that’s most or all of a semester for a college student and can set into motion a downward spiral if the student has no supports to help work through it.
Two SLPs’ Story of TBI Recovery and Lessons Learned

A near-fatal car accident left clinical fellow Laura Morgan (right) with a serious traumatic brain injury. She and colleague Anna Miller describe the personal resolve and social support required during her challenging and remarkable recovery. They also share first-hand advice for clinicians on supporting people through TBI rehabilitation.

Aiding mild TBI
At the University of Tennessee, Kristin King helps run a program that assists students as quickly as possible. “Within two to four weeks of the injury, we have set up needed accommodations,” says King, an assistant professor in the Department of Audiology and Speech Pathology. “It used to take three months.”
The program works in concert with the university’s Office of Disability Services. A student with a mild brain injury or concussion receives medical evaluation, cognitive and behavioral tests, and periodic monitoring. Classroom accommodations—which can include extra testing time, administering exams in a quiet room, or postponement of assignments or tests—also are established.
After four weeks of accommodations, students are retested by a university SLP or their own physician. Most decisions about whether to continue accommodations are made through the Office of Disability Services.
“A majority of students only need accommodations for those four weeks,” King says. “But professors cover a massive amount of information in four weeks, so if you’re in there with headaches or an inability to concentrate, you’re going to miss a big chunk of the class.”
King cautions that assessments do not always catch the effects of mild TBI that can cause problems for college students. “People can generally look OK, tests come out OK, but they’re not OK,” she says. “They tend to report trouble paying attention in class, losing track of lectures. Or multitasking—if the professor is putting things on the board and lecturing at the same time, the student is trying to take down notes and focus on what’s being said. It can become very difficult. It’s too much information to process.” And it’s exhausting, she says—fatigue is another common symptom.
At UW-Madison, students with mild TBI visit the university’s concussion clinic right away, says Turkstra. Most don’t need to apply for disability accommodations. “They get study help and strategies at the clinic, and recover within weeks,” she says.
“The model for mild TBI is a wellness model: How can we help you be as healthy as possible?” says Turkstra. “The model for moderate or severe TBI is more of a chronic disease model—you’ll have this condition for life and we’re here to help you manage it.”
Assisting veterans
Veterans are a growing student population dealing with the effects of TBI. The federal Post-9/11 GI Bill provides tuition and a housing stipend to active-duty service members, and more than 2 million veterans have accessed these benefits. Many feel a need to take advantage of the benefits quickly, says Karen Gallagher, clinical associate professor in the Department of Speech and Hearing Science at Arizona State University.
“They start taking college courses whether they are ready or not,” says Gallagher. “They want to access their benefits to feed and house their family.”
Gallagher is an Army veteran who served in Desert Shield and Desert Storm as an airborne nuclear, biological and chemical specialist. She notes that although ASU is one of the most veteran-friendly universities in the country, a subgroup of veteran students still drops out—quickly, after only one or two semesters. Gallagher is working toward her doctoral degree, focusing on memory and attention in veterans who enter or return to college. “I have always identified with this population—it’s extremely difficult to transition [from military to civilian life],” Gallagher says.
Her research is still under way, but Gallagher says that many veterans have told her, “There’s something different about the way I learn now.” With the most common injuries from the recent wars being TBI and post-traumatic stress disorder, the effects on learning can be substantial.
Gallagher is also still a practicing SLP, providing short-term, intensive services with a focus on strategies for dealing with auditory distractions and note-taking. “We work on showing them which strategies work and which don’t work, and how we can facilitate getting them additional accommodations,” she says.
Back in Minnesota, Kacie Carlsted, the student who sustained a severe TBI in a car accident, is reaping the benefits of this sort of support: One year after withdrawing from college, Carlsted started at Augsburg College, her original choice. After receiving her bachelor’s degree, she began working with AmeriCorps as a math tutor in an elementary school.
“I made it through college because of all the support from the people who helped me: Dr. Kennedy, Augsburg’s disability services, faculty and other staff members,” she says. “I don’t think I would have been able to do it without them.”
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December 2015
Volume 20, Issue 12