Perspectives on Neurophysiology and Neurogenic Speech and Language Disorders

Volume 25, January 2015, Copyright © 2015 American Speech-Language-Hearing Association

Assessment of Cognitive-Communication Disorders

in Adults with Mild Traumatic Brain Injury
Heather Krug
Department of Communication Sciences and Disorders, University of Wisconsin-Madison
Madison, WI

Lyn S. Turkstra
Department of Communication Sciences and Disorders, University of Wisconsin-Madison
Madison, WI
Financial Disclosure: Heather Krug is Clinical associate professor at the University of
Wisconsin-Madison. Lyn S. Turkstra is a professor at the University of Wisconsin-Madison.
Nonfinancial Disclosure: Heather Krug has previously published in the subject area. Lyn Turkstra
has previously published in the subject area.

Abstract
Mild traumatic brain injury (mTBI) has been in the news lately, particularly mTBI in school-
aged children, professional athletes, and service members and veterans. College students
have received less attention, but college students also are at high risk for mTBI, and
lasting impairments can have major effects on academic performance. Speech-language
pathologists (SLPs) can play an important role in supporting college students with mTBI, and
several universities are developing concussion clinics directed by SLPs. In this paper, we
describe our experience developing an SLP-run college concussion clinic in collaboration with
peers and other team members. We present our protocol for assessment and guidelines for
management and referral.
Several years ago, a psychiatrist from our campus student health services asked our
advice about treating students with a history of mild traumatic brain injury (mTBI). These included
students with uncomplicated mild injuries and also those with complicated injuries (e.g., a history
of concussion, comorbid medical, or psychiatric conditions). National awareness of morbidity after
mTBI was increasing, and the psychiatrist noted that student health services had no protocol for
treating students who presented with either recent or remote histories of mTBI. In response, we
assembled a team of healthcare providers, coaches, and trainers, with the aim of identifying staff
training needs and developing a triage plan for students with mTBI. One part of the protocol is
a College Concussion Clinic, which is part of the Speech and Hearing Clinic of the Department
of Communication Disorders and Sciences. The clinic provides assessment and treatment of
students with mTBI-related symptoms that interfere with schoolwork. We accept referrals from
any source, including self-referrals. Assessment is the cornerstone of managing mTBI, and in this
article, we share our experience developing the assessment protocol for our clinic.
To develop the protocol, we sought input from speech-language pathology colleagues at
other universities with similar clinics, as well as colleagues working with soldiers and veterans with
mTBI. We also searched the available literature and resources such as the Centers for Disease
Control and Prevention (CDC) Concussion and Mild Traumatic Brain Injury website (CDC, 2014).
The consensus across all of these sources was that evaluation of patients with mTBI should include,
at minimum, a problem-focused interview and completion of a checklist of post-concussion
symptoms. Beyond the interview and checklist, assessment was tailored to the communication
needs of the patient. Thus, in this article we present ideas for a problem-focused interview,
examples of common symptom checklists, and tests used by some centers for evaluation of patients
for whom mTBI has affected their ability to perform everyday communication activities.

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 We emphasize that this article represents our experience only, and that although there
are extensive guidelines for evaluation by neuropsychologists, to our knowledge there are no
empirical data to support specific recommendations for assessment by speech-language pathologists
(SLPs). The involvement of SLPs in clinical management of individuals with mTBI is growing, so
guidelines for practice with this population are likely to emerge in the next few years. A second
caveat is that procedures and measures discussed here focus only on individuals with symptoms
lasting longer than two months, which our multidisciplinary team chose as the trigger for referral
to our clinic. As the vast majority of individuals with mTBI recover completely, at least from a
behavioral perspective, this criterion was designed to identify those in most need of speech-language
pathology services rather than medical recommendations and accommodations.
This article describes speech-language pathology intervention, but management of clients
with mTBI requires close collaboration with other healthcare providers. These include clinical
psychologists and social workers, who may be managing psychosocial consequences of cognitive
and somatic symptoms; neuropsychologists who have tools that are sensitive to types of cognitive
impairments that are common among individuals with mTBI; physical therapists who may be
addressing vestibular and physical symptoms; neuro-ophthalmologists and vision therapists
(orthoptists and occupational therapists) who specialize in management of mTBI symptoms such
as impaired visual tracking and convergence; and neurologists and physiatrists who manage
headaches and other somatic symptoms. For children, school nurses also are a critical member of
the team, as they have an important role in monitoring activity-based symptoms over time, and
family physicians likewise monitor ongoing recovery and coordinate care. It also is important to
communicate with other stakeholders outside of the healthcare system, such as teachers, trainers,
coaches, family members, and others who will be interacting with the person with mTBI on a daily
basis.

Problem-Focused Interview
The first step in our protocol is a problem-focused interview. Because assessing the
cognitive-communicative functioning of individuals with mTBI is an emerging area of clinical
practice, our problem-focused interview protocol was developed based on the consensus guidelines
referenced above and the research literature associated with moderate and severe TBI. The majority
of our clients are full-time university students, so the problem-focused interview was designed to
emphasize the interface between cognitive-communicative symptoms and demands of the academic
environment. For non-students, or students who also have concerns about performance at work,
we expand the academic protocol to include workplace concerns, based on specific needs. For
students who also have concerns about performance at work, we expand the protocol to include
individualized interview questions about work performance. The interview protocol includes four
components that are adapted to the individual client’s profile: (1) a detailed history to evaluate risk
factors for post-concussion syndrome (PCS) such as sex (females are at higher risk than males),
mechanism of injury (e.g., simple sports concussion vs. concussion from a motor vehicle accident
with comorbid physical damage), and history of prior concussions, as well as pre-injury academic
performance; (2) assessment of cognitive-communicative complaints; (3) assessment of academic
needs and environmental demands; and (4) assessment of client-generated compensations
and strategies that the student attempted to use and/or used on an ongoing basis. Examples of
interview questions that we use to elicit information about these four components are included in
Appendix A.
When developing the problem-focused interview protocol, we first selected clinical interview
questions likely to yield information most relevant to clients’ functioning. For instance, we included
questions regarding changes in attention, recall and executive functions, because these cognitive
symptoms are associated with mTBI (Caplan et al., 2010; Cicerone & Kalmar, 1995). We further
predicted that clients’ cognitive-communicative concerns might have some overlap with the
cognitive-communicative deficits associated with moderate and severe TBI. For instance, adults

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 with moderate to severe TBI often have deficits in attention, memory, information processing,
and executive functions (Levin, 1995); thus, we included questions about these function in our
interview.
Next, based on our prior experiences with individuals with mTBI in other settings, including
Veterans Administration (VA) Medical Centers and community outpatient clinics, we anticipated
that some clients might demonstrate symptoms associated with dysexecutive syndrome. We
surmised that executive functioning challenges might limit a client’s ability to efficiently and
independently identify, express, summarize, and prioritize their concerns when faced with an
open-ended interview question format. Our intent was to obtain the most accurate representation
of clients’ and stakeholders’ perspectives as efficiently as possible. Thus, our chosen method and
approach was to balance open-ended interview with more structured closed-set response formats.
Last, we drew from already-established checklists and rating scales designed for the general
TBI population, including the Everyday Memory Questionnaire (Sunderland, Watts, Baddeley, &
Harris, 1986) and the College Survey for Students with Brain Injury (Kennedy, Krause, & Turkstra,
2008) as well as the Problems Checklist (Herrmann & Parente, 2010). We then further modified
our interview questions and checklists in response to known or anticipated environmental demands
most likely to influence undergraduate and graduate students’ academic and social success at
UW-Madison. The basis for these changes was informed by feedback and observations from clients
and other team members, including physicians, instructors, services for students with disabilities,
and mental health providers.
One of our most frequently used checklists is the Academic Needs Assessment (ANA),
which was developed in our clinic (see Appendix A). The ANA is self-rated checklist that compares
performance of academic tasks before and after concussion. We also use checklists that ask the
client to rate their effectiveness and efficiency when performing academic tasks.
As we continued to refine the problem-focused interview protocol (and subsequently the
recommendations and treatment process), we saw a need to expand the protocol to include a
solution-focused interview component. The solution-focused portion of the clinical interview (see
Appendix A) was designed to facilitate exploration of the client’s attitudes, opinions, and experiences
relating to attempted solutions for cognitive-communicative difficulties. Information about solutions
helps the client identify self-generated compensations that may in fact already be effective or might
be modified to increase the likelihood of successful outcomes. Swift transition to a solution focus
and acknowledgement of successful actions seemed to optimize sense of self-determination,
momentum, motivation, and willingness to try or continue to use recommended strategies. Used
in concert with standardized assessment measures (described below), the solution-focused phase
of the clinical interview allowed the clinician and client to collaboratively match types of compensations
most likely to be of benefit, and identify academic accommodations and modifications that we
later request from the office providing services to students with disabilities.

Post-Concussion Symptom Checklists

Post-concussion symptom checklists are a means of efficiently documenting and tracking
a client’s symptoms post-concussion. Selection of symptoms included in these checklists is based
on two early studies of mTBI cognitive outcomes. The first was a multi-center, longitudinal study
of mTBI outcomes by Levin and colleagues (1987), who interviewed 57 patients with mTBI at one
month post-injury. Cicerone and Kalmar (1995) used results from the Levin et al. (1987) interviews
to create a symptom checklist, which they administered to 51 adults with a mTBI history who
were 3–52 months post-injury. These two studies revealed a constellation of affective, somatic,
sensory, and cognitive symptoms that were commonly reported by patients with mTBI in the early
stages, and by a subset of patients up to several months or years after injury. Findings from these
studies have been replicated in larger military and civilian samples (e.g., Lange, Brickell, Ivins,
Vanderploeg, & French, 2013; Teasdale et al., 1997), supporting the content validity of the checklists,

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 although there is some controversy about specificity of complaints (i.e., the base rate of typical
post-concussion symptoms in the general population; Chan, 2001). Post-concussion symptom
checklists involve the client’s self-report of severity of symptoms, which typically are ranked
numerically using Likert scales or endorsed via binary yes/no responses. Such checklists are
primarily administered by members of the healthcare team, including physicians, nurses, coaches,
and athletic trainers. In sports, post-concussion symptom checklists are usually first used on the
sidelines by physicians, sports medicine practitioners, medics, other medical personnel immediately
after injuries in which there is a suspicion of concussion. Symptoms are then monitored over time.
In cases when symptoms have not been documented by other team members, or not documented
recently, such as in non-sports injury, the SLP may be the first person to administer a checklist and
communicate results to the healthcare team. In our experience, individuals with non-sports
concussions are less likely to present with prior documentation of symptoms than athletes who
have sustained an mTBI, as athletes are more likely to have a system of evaluation in place. In
either case, documenting and monitoring symptoms using symptom checklists is very beneficial.
These assessments screen for unrecognized or persistent unaddressed symptoms in an efficient
manner, and generate important information for the medical team. Use of consistent reporting
measures allows for comparison of symptoms over time and across settings, which may reflect
changes in status or responses to various medical and strategic interventions.
Clients may come to SLPs in varying stages of the evaluative and therapeutic process, and
may have received varying degrees of support and intervention from other disciplines. In our clinic,
most clients have already completed symptom checklists because most are athletes and were
assessed on the sidelines. In this case, a useful application of symptom checklists is to compare
post-concussion symptoms before and after administration of standardized cognitive-communicative
assessments. The comparison measures can help to determine the impact of cognitive effort or
exertion. Such findings, along with other diagnostic information, can inform recommendations for
the medical team regarding recommended levels of cognitive activity or cognitive rest.
Post-concussion symptom checklists can also prove useful in educating clients and their
stakeholders about potential interactions among cognitive, physical, and affective symptoms.
In mTBI, factors like physical effort, anxiety, and lack of sleep can make cognitive symptoms
worse. Review of cognitive symptoms in tandem with physical and affective symptoms provides a
forum to consider the relationship among these different types of symptoms and highlight the
potential academic benefits of managing physical and affective symptoms.
There are a number of symptom checklists available for use. Three frequently used
checklists available free of cost are the Acute Concussion Evaluation (ACE; Gioia & Collins, 2006),
Neurobehavioral Symptom Inventory (NSI; Cicerone & Kalmar, 1995), and the Symptom Evaluation
portion of the Sports Concussion Assessment Tool 2 (SCAT2; 2009). Varsity athletes seen in our
clinic often have been evaluated pre-season using the Immediate Post-Concussion Assessment and
Cognitive Testing (ImPACT), a for-purchase assessment system that includes a symptom checklist.
The NSI is routinely used in the VA with veterans who have sustained blast injury and
other causes of concussion. This measure involves self-rating of severity of symptoms experienced
over the preceding 2 weeks. It includes 22 complaints frequently reported following concussion,
including the following: problems with balance; dizziness; sensitivity to light or noise; irritability;
poor concentration; forgetfulness; difficulty making decisions; and sleep disturbance. The NSI uses
a rating scale of 0 (no symptoms) to 4 (very severe symptoms).
The SCAT2 Symptom Evaluation is another tool frequently used to evaluate severity of
injured athlete’s symptoms following injury and suspected concussion. It is designed for individuals
ages 10 years and older. The SCAT2 Symptom Evaluation asks the client to rate 22 symptoms
associated with concussion, including the following: headache; blurred vision; difficulty concentrating;
difficulty remembering; fatigue or low energy; confusion; feeling slowed down; irritability; feeling
“like in a fog”; and drowsiness. Ratings are based on how the client is feeling at “the present/during
the time of the assessment in clinic”. The client gives self-ratings on a scale of 0 (no symptoms)
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 to 6 (severe symptoms). The SCAT2 also asks the client to evaluate if symptoms worsen with physical
or mental activity. It further records collateral ratings from a person who knows the athlete well,
comparing the individual’s behavior pre- and post-injury as “no different”, “very different”, or
“unsure.” The SCAT2 also includes cognitive and physical evaluations.
The NSI and SCAT2 are designed primarily for use in outpatient clinic settings. There are
also “sidelines” measures that are administered at the time of injury, either during sporting events
or in military theater. Sidelines assessment of post-concussion symptoms enables the medical
team to make rapid decisions about recommendations for rest or return to competition or combat
immediately after injury. Recently, numerous low-cost mobile applications for post-concussion
symptom tracking have been developed for use on smartphones and tablets, further increasing
ease of administration. Examples of such apps are described in Appendix B.

Standardized Testing
For many clients, a problem-focused interview and symptom checklist may provide enough
information to identify short-term academic accommodations and strategies that will support the
student through his or her recovery. If a patient has persistent symptoms or specific communication
complaints, however, or performs occupational, educational, or social communication functions
that are likely to be affected by mTBI symptoms, the SLP might give a standardized test to quantify
impairments in specific cognitive and communication domains. Two general types of standardized
tests might be used: (a) omnibus tests that give an overview of functions in a variety of cognitive
domains, and (b) tests of specific cognitive and communication functions. Sample tests are presented
in Table 1, with strengths and limitations of each.

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 Table 1. Example Tests of Cognitive and Communication Functions.

Test Purpose Strengths Limitations

Omnibus tests:
Brief, broad Repeatable Battery for the To determine the Broad sample of cognitive Sensitivity and specificity
cognitive Assessment of neuropsychological status of functions, strong construct for problems associated
assessment Neuropsychological Status adults ages 20–89 with validity, availability of with mTBI have not been
(RBANS) neurologic injury or disease, multiple forms for test-retest determined.
such as dementia, head
Randolph (2001) injury, or stroke
The Psychological Corporation
Domain-specific
tests:
Attention Test of Everyday Attention (TEA) Measures selective Three versions are available: Standardized on individuals
attention, sustained A, B, and C. Test-retest with unilateral stroke not
Robertson, Ward, Ridgeway, & attention, and attentional reliability meets relaxed TBI. Small standardization
Nimmo-Smith (1994) switching using everyday criterion after 1 week on sample: 154 adults ages
Thames Valley Test Company materials. Developed for alternate forms, but only for 18–80 years.
use with clinical and typical overall score. Has four factors that do not
populations.
22

correspond to four cluster

scores.

Information WJ-III Cognitive Battery To measure cognitive
Processing efficiency (i.e., individual’s
Speed Woodcock, McGrew, & Mather ability to perform automatic
(2001) cognitive tasks under
Riverside Publishing pressure and with focused
attention).
Standard Battery
Test 6: Visual Matching
Extended Battery Tests 16:
Decision Speed; 18: Rapid
Picture Naming; and 20:
Pair Cancellation.
Large standardization sample. Relatively limited norms for
Test-retest reliability meets adults compared to children
relaxed criterion for children (e.g., test-retest reliability
ages 7–11 years (test-retest data are from 54 adults ages
correlation for adults is .70). 26–79 years). Individuals
Item reliability meets strict with TBI not included in
criterion. Cluster and total standardization sample.
scores have modest
correlations with similar tests.
Factor analysis shows that
speed is a separate factor
with low correlations with
other factors.

(continued)

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 Executive Functional Assessment of To assess verbal reasoning,
functions Verbal Reasoning and complex comprehension,
Executive Strategies discourse, and executive
(FAVRES) function in order to
determine the presence and
MacDonald (1995) CCC severity of higher level
Publishing cognitive communication
deficits. Requires
processing of real world
information, integration of
stimuli, and formulation of
written and oral responses.
Declarative Rivermead Behavioral Memory To identify everyday
Memory Test (RBMT) – Version 3 memory problems and
monitor change over time.
Wilson et al. (2008) Third edition includes novel
Pearson Assessments task learning.
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Scores differed significantly
between adults with and
without TBI. Based on
standardization sample,
specificity and sensitivity for
differentiating adults with
vs. without TBI were .83 or
better when scores for
Accuracy and Rationale
were combined. Inter-rater
reliability met relaxed
criterion.
High inter-rater reliability.
Good face facility. Moderate
correlation with clinician
reports of everyday memory
problems and low but
significant correlations with
patient-reported memory
problems. Low to moderate
correlation with scores on
other memory tests.
Adults with mTBI not
included in the
standardization sample.
Test requires relatively high
level of literacy, although
there was no significant
correlation between total
scores and age, education,
or occupation.
14 subtests but factor
analysis supports only the
General Memory Index
score (i.e., subtest scores
not interpretable as stand-
alone scores)
Clinical sample in
standardization included
only 19 adults with TBI,
none with mTBI. Alternative
form reliability moderate,
limiting use in measuring
change over time.
(continued)
 Contextual Contextual Memory Test To assess awareness of Parallel version reliability
Memory and memory capacity and to meets relaxed criterion for
Meta-Memory Toglia, J. (1993) Pearson determine the extent to which Context items Delayed and
Assessment an individual is responsive Total scores, and Prediction
to cues aimed at enhancing scores. Item separation
strategy use and recall. reliability (extent to which
item scores distribute along
a continuum) meets strict
criterion; person separation
reliability (extent to which
total scores distribute along
a continuum) meets relaxed
criterion for delayed recall of
Restaurant story and strict
criterion for Total Recall
score. Criterion validity meets
relaxed criterion. Based on
the standardization sample,
specificity and sensitivity for
Total, Immediate, and
Delayed forms were .80 or
better, and adults with TBI
24
were significantly less
accurate at predicting
performance and had lower
strategy scores than
uninjured adults.
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Standardization sample
included only 112 “patients
with brain injury ranging in
age from 17 to 88”, and 191
controls.
Manual states that
“approximately 69% of
variance of the scores can
be accounted for by the
same general factor” but it
is not clear if this refers to
the CMT or the CMT
correlation with the RBMT.
If it’s the former, this
suggests that the CMT is
essentially a one-factor test.
Test-retest reliability not
tested.
(continued)
 Meta-memory Everyday Memory
Questionnaire
Sunderland, A., Harris, J. E., &
Baddeley, A. D. (1983). Do
laboratory tests predict everyday
memory? A neuropsychological
study. Journal of Verbal
Learning & Verbal Behavior,
22(3), 341–357.
Language Controlled Oral Word
Association (COWA) Subtest
of the Multilingual Aphasia
Examination
Benton, Hamsher, Rey, &
25
Sivan (1994)
The Psychological Corporation
Language WJ-III Cognitive Battery
Test 1: Verbal Comprehensiond
Woodcock, McGraw, &
Mather (2001)
Riverside Publishing
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To assess memory
functioning in everyday life
using self- and informant
ratings. Originally developed
for TBI but has been used
with other clinical
populations (e.g., dementia,
multiple sclerosis, stroke).
Original questionnaire has
35 items but 28-item version
is most commonly used.
There are 20–item, interview
format, and child versions.
To provide a relatively brief
but detailed examination of
the presence, severity, and
qualitative aspects of
aphasic language disorders
for patients between 6 and
69 years of age.
To measure lexical
knowledge, vocabulary
knowledge, and lexical
reasoning via picture
vocabulary, synonyms,
antonyms, and verbal
analogies.
Designed to have ecological
validity.
Includes items for episodic
memory, procedural memory,
and prospective memory, and
both visuospatial and verbal
memory.
35-item version has good
internal consistency,
construct validity, and test-
retest reliability.
Discriminates typical adults
from adults with TBI, and
mTBI vs. severe TBI.
High inter-scorer reliability
and moderate test-retest
reliability within one month.
Well-established construct
and concurrent validity.
Widely used test of breadth
of verbal knowledge.
Questionnaire has been
used in a variety of formats
(e.g., 28 vs. 35 questions,
ratings from 1–4 vs. 1–9).
Developed on a small
sample of adults with TBI
in England.
Sensitivity and specificity
not reported (i.e., debate in
the literature about whether
it can be used for diagnosis),
so there is a risk of over-
diagnosing problems in
adults with mTBI.
Originally intended for
individuals with aphasia,
but widely used as a test of
executive functions related
to language (e.g., verbal
fluency and semantic
organization).
Test was constructed on a
developmental model not
criterion-referenced for
individuals with acquired
problems. Lexical knowledge
and language development
are not typically impaired by
mTBI. Relatively limited
norms for adults compared
to children (e.g., test-retest
reliability data are from 54
adults ages 26–79 years).
Overall, 1,843 adults
were included in the
standardization but none
had TBI.
(continued)
 Language WJ-III Achievement Battery Story Recall: To measure Widely used test of verbal Potentially confounds
Oral Language Cluster (Test 3: aspects of oral language recall in progressively more language with sustained
Story Recall, and Test 4: including meaningful complex and longer spoken and focused attention,
Understanding Directions) memory and language stories. working memory, and
development. declarative recall.
Woodcock, McGrew, & Relatively limited norms
Mather (2001) Understanding Directions: for adults compared to
To measure the ability to children (e.g., test-retest
Riverside Publishing
understand and execute a reliability data are from
series of directions. 54 adults ages 26–79 years).
Overall, 1,843 adults were
included in the
standardization but none
had TBI.
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 As with other aspects of mTBI management, there are no data-based guidelines about
which test to use and when. In our practice, we choose specific tests based on the client’s chief
complaint and the problem-focused interview. In some cases it is helpful to have an omnibus test
such as the Repeatable Battery for the Assessment of Neuropsychological Status, if the patient can
tolerate that length of testing, to permit comparison across clients and communicate with other
providers who are familiar with the test. As with all tests, it is important to keep in mind that
subtest scores can only be interpreted individually if they represent discrete constructs of the test.
Thus, scores on individual subtests might be best interpreted as guideposts for further assessment
with domain-specific tests like those listed in Table 1. It also is important to recognize that visual
and vestibular problems can affect test taking as well as performance in class, and problems in
these domains must be considered when interpreting test performance.

Conclusion
SLPs’ involvement in assessment of clients with mTBI is a growing area of practice, and in
need of evidence-based practice guidelines. We benefited greatly from the experience of others, who
taught us the importance of responding flexibly and rapidly to changing student needs, documenting
and tracking post-concussion symptoms, collaborating with the multi-disciplinary healthcare team
and other stakeholders involved in the client’s return to learning, and focusing assessment on
what the student can do to return to classes as quickly and effectively as possible, rather than
focusing on impairments. As we learn more about the short- and long-term challenges of individuals
with mTBI, we will better understand how SLPs can contribute to successful cognitive and
communication outcomes for these individuals.

Acknowledgements
The authors wish to thank Kathryn Hardin, Dr. Kristin King, and Dr. Rebecca Morgan
for sharing information about their own concussion clinics, which are a model for academic
concussion clinics; Dana Longstreth and Peggy Rosin, co-founders of the UW-Madison Clinic; and
the members of the mTBI Assessment Sub-Committee of the Department of Defense/Department
of the Navy/Veterans Administration committee to develop practice guidelines for mTBI, for
contributing to Table 1.

References
Benton, A., Hamsher, K., Rey, G., & Sivan, A. (1994). Multilingual Aphasia Examination-Controlled Oral Word
Association Subtest (First ed.). San Antonio, TX: The Psychological Corporation.
Caplan, L. J., Ivins, B., Poole, J. H., Vanderploeg, R. D., Jaffee, M. S., & Schwab, K. (2010). The structure
of postconcussive symptoms in 3 US military samples. The Journal of Head Trauma Rehabilitation, 25(6),
447–458.
Chan, R. C. (2001). Base rate of post-concussion symptoms among normal people and its neuropsychological
correlates. Clinical Rehabilitation, 15(3), 266–273.
Centers for Disease Control and Prevention [CDC]. 2014. Concussion and mild TBI. Retrieved from
http://www.cdc.gov/concussion/index.html
Cicerone, K. D., & Kalmar, K. (1995). Persistent postconcussion syndrome: The structure of subjective
complaints after mild traumatic brain injury. The Journal of Head Trauma Rehabilitation, 10(3), 1–17.
Gioia, J., & Collins, M. (2006). Acute Concussion Evaluation. Available from the Centers for Disease Control
and Prevention. Retrieved from http://www.cdc.gov/concussion/headsup/physicians_tool_kit.html
Herrmann, D., & Parente, R. (2010). Retraining Cognition: Techniques and Applications (2nd ed.). Austin, TX:
ProEd Inc.
Kennedy, M. R., Krause, M. O., & Turkstra, L. S. (2008). An electronic survey about college experiences after
traumatic brain injury. NeuroRehabilitation, 23(6), 511–520.

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 Lange, R. T., Brickell, T. A., Ivins, B., Vanderploeg, R. D., & French, L. M. (2013). Variable, not always
persistent, postconcussion symptoms after mild TBI in U.S. military service members: a five-year cross-
sectional outcome study. Journal of Neurotrauma, 30(11), 958–969.
Levin, H., Mattis, S., Ruff, R. M., Eisenberg, H. M., Marshall, L. F., Tabaddor, K., . . . Frankowski, R. F. (1987).
Neurobehavioral outcome following minor head injury: a three-center study. Journal of Neurosurgery, 66,
234–243.
Levin, H. S. (1995). Neurobehavioral outcome of closed head injury: implications for clinical trials. Journal of
Neurotrauma, 12(4), 601–610.
MacDonald, S. (2005). Functional assessment of verbal reasoning and executive strategies. Guelph, Ontario:
CCD Publishing.
Randolph, C. (2001). Repeatable battery for the assessment of neuropsychological status (First ed.).
San Antonio, TX: Psychological Corporation.
Robertson, I. H., Ward, T., Ridgeway, V., & Nimmo-Smith, I. (1994). The test of everyday attention: TEA.
San Antonio, TX: Pearson.
Sports Concussion Assessment Tool 2 (SCAT-2). (2009). British Journal of Sports Medicine, 43, i85–i88.
Sunderland, A., Harris, J. E., & Baddeley, A. D. (1983). Do laboratory tests predict everyday memory?
A neuropsychological study. Journal of Verbal Learning & Verbal Behavior, 22(3), 341–357.
Sunderland, A., Watts, K., Baddeley, A. D., & Harris, J. E. (1986). Subjective memory assessment and test
performance in elderly adults. Journal of Gerontology, 41(3), 376–384.
Teasdale, T. W., Christensen, A. L., Willmes, K., Deloche, G., Braga, L., Stachowiak, F., . . . Leclercq, M.
(1997). Subjective experience in brain-injured patients and their close relatives: a European brain injury
questionnaire study. Brain Injury, 11(8), 543–563.
Toglia, J. P. (1993). Contextual memory test. New York: Pearson.
Wilson, B. A., Greenfield, E., Clare, L., Baddeley, A., Cockburn, J., Watson, P., . . . Nannery, R. (2008).
Rivermead Behavioural Memory Test (3rd ed.). New York: Pearson.
Woodcock, R. W., & Mather, N. (1990). Woodcock-Johnson Psycho-Educational Battery–Revised. Allen, TX:
DLM Teaching Resources.

History:
Received September 8, 2014
Revision received December 19, 2014
Accepted December 22, 2014
doi:10.1044/nnsld25.1.17

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 Appendix A. University of Wisconsin-Madison College Concussion
Clinic case history and academic needs assessment.

Name: Date Hx Taken:

DOB: Interviewer:
Address: Informant:

Phone:
Referral Source:

MEDICAL CONDITIONS/SURGERIES:
SENSORIMOTOR FUNCTIONING (hearing, vision, balance, handedness, movement challenges/
aids):

CURRENT MEDICAL DIAGNOSTICS (labs, imaging):

MENTAL HEALTH & PSYCHIATRIC HX/CURRENT TREATMENT FOR MENTAL HEALTH

CONDITIONS:

MEDICATIONS:

DRUG/ALCOHOL/TOB USE/HISTORY:

ALLERGIES/PRECAUTIONS (work/academic rest, foods, meds, swallowing, movement, other

precautions)

CONCUSSION EVENTS/SYMPTOMS:
How many concussions? When? What happened?
Describe symptoms after each:
Loss of consciousness (LOC)?
Duration of LOC:
Physical symptoms:
Cognitive symptoms: e.g., memory loss, feeling hazy, slow, foggy

When was the first concussion?

When was the most recent concussion?

(continued)

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 Differences/similarities
Date Situation Symptoms
Concussion 1
Concussion 2
Concussion 3

What symptoms are you experiencing now?

Physical?

Cognitive (concentration, memory, decision-making, multitasking)?

Mood?

Sleeping?

How have these symptoms changed since the last concussion?

Are you seeing any other health professionals about specific symptoms? Who? For what?
How long? Helpful?

What makes the symptoms worse?

Does anything help alleviate the symptoms?

VOCATIONAL HISTORY/STATUS:

SOCIAL:

ACADEMIC HX:

Highest level education/degrees completed:

Is English first language? Other languages spoken?

How was high school? A/B, B/C, C/D grades?

Best HS subjects:
Worst HS subjects:

Any help for reading/dyslexia/attention/speech-language/learning disability?

If yes, what accommodations/modifications/therapies/medications were provided? Which ones
were helpful?
Enjoyed reading in the past? Now?

(continued)

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 CURRENT SCHOOL STATUS
Class standing: FR SO JR SR GRAD: ______
Date started coursework: Est. graduation date:

Academic Major:

Vocational Goal:

GPA prior to concussion: Current GPA:

Classes/credits taken:
Spring:

Summer:

Fall/current semester courses:

Struggling in which courses? Excelling/going as expected?

Recent Grades (course, tests, quizzes, written assignments)

General academic performance before concussion(s)?

Receiving accommodations/modifications currently?

Discussed difficulties w/ instructors/disabled student services?

What feedback have you received from your instructors and advisors regarding your current
academic performance? If they have not given you explicit feedback, how do you think they are
perceiving your performance at present?

(continued)

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 ACADEMIC NEEDS ASSESSMENT
What school-related activities have been difficult for you since your last concussion? Please rate
your performance on a 1–5 scale. (“1” = worst possible/of most concern to you and “5” = best
possible/of little to no concern to you) Please rate your performance now, as well as prior to your
most recent concussion.
Now Prior to Most
Recent Concussion

Follow information discussed during lectures

Take accurate class notes that help you study later on
Understand information that you read in textbooks/articles
Express your point during class discussions
Work together on group projects
Maintain focus while studying
Identify and prioritize the most important information to study
Multi-task
Manage time effectively
Approach studying and school in an organized fashion
Ask questions that help you learn new information
Put information that you learn in your own words
Retain new information
Summarize what you have learned
Do research for papers
Write papers and essays
Do formal presentations
Take tests/quizzes
Communicate with your instructors/classmates
Stay motivated and committed to studying
Stick to study schedule/study consistently
Maintain mental endurance/energy (no mental fatigue)
Any additional special requirements/challenges of coursework
(continued)

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 STUDY SKILLS/STRATEGY USE

How do you study?

-Time spent studying/day?
-Time of day?
-Study methods?
-At the library, coffee shop, home, etc?
-Alone, study groups?

How do you work on projects, papers, etc?

What have you found to help with school, work/what is going well in your studies?

Confidence in your ability to succeed in school? (Rate on 1-10 scale)

SELF CARE
What do you do to relax? Manage or reduce stress?

DESIRED OUTCOMES/POTENTIAL SOLUTIONS

What would you most like to see change in your studies or academic performance as a result of
coming to this clinic?

What do you think would help you perform better in school?

How will you know your memory (planning/organizing/thought formulation/other cognitive

domain) is better? [indicators]

What do you believe would make things easier for you/make you more productive/successful?

What is the most important factor in your success in “x” class?

(continued)

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 Appendix B. Mobile Apps to Evaluate Post-Concussion Symptoms.
NAME & DEVELOPER FEATURES PLATFORM & PRICE

Concussion Recognition & Response • designed for parents & coaches by Gerard iOS
– PAR, Inc. Gioia, Ph.D. (Pediatric Neuropsychologist, ($0.99)
director of SCORE Concussion program)
https://play.google.com/store/ & Jason Mihalik Ph.D.
apps/details?id=com.parinc.crr Android
• symptom questionnaire with yes/no
(free)
response format
https://itunes.apple.com/sn/app/ • identifies whether concussion is likely
concussion-recognition-response/ or not
id436009132?mt=8 • gives response & management
suggestions
Play it Safe – Concussion Health, LLC • designed for athletic trainers & coaches iOS
• symptom questionnaire (free)
https://itunes.apple.com/us/app/
• timers for measuring cognitive function
play-it-safe-concussion-assessment/
& balance
id441786934?mt=8
• email reports to healthcare team
members
SCAT2 - Sport Concussion & • designed for healthcare providers iOS
Assessment Tool 2 – Inovapp Inc. • app version of the SCAT2 ($3.99)
https://itunes.apple.com/sn/app/ • email tests to other team members
scat2-sport-concussion- • stores tests for baseline and post-injury
assessment/id452857229?mt=8 comparisons over time

Concussion – SportSafety Labs, LLC
https://itunes.apple.com/us/app/
concussion/id418559920?mt=8
• lists signs & symptoms of concussion iOS
• provides 911 access & map to locate (free)
nearest hospital
• with $4.99 in-app purchase: store
baseline and post-injury measures for
comparison; email evaluations and
receive communication from physician
regarding recommendations for return
to play
(continued)

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 Heads Up App – National • developed by the CDC Android
Foundation Center For Disease • separate parent, coach, and clinician (free)
Control And Prevention Inc. versions available
https://play.google.com/store/ • advice for suspected concussion iOS
apps/details?id=org.cdcfoundation. • brain injury information (free)
androidapp • prevention and safety tips, including
helmet selection
https://itunes.apple.com/us/app/
heads-up-app/id668188486

Sideline ImPACT - ImPACT • designed by developers of the ImPACT iOS

Applications, Inc. Test ($3.99)
• brief screen for symptoms immediately
https://itunes.apple.com/us/app/ after injury
sideline-impact/id660066713?mt=8
PCSI (Post Concussion Symptom • designed by developers of the ImPACT iOS
Inventory) - ImPACT Applications, Inc. Test ($3.99)
• electronic app version of PCSI of ImPACT
https://itunes.apple.com/us/app/
pcsi/id660023511?mt=8

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