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Neuropsychological Rehabilitation
The International Handbook
Barbara A. Wilson, Jill Winegardner, Caroline M. van Heugten, Tamara
Ownsworth

Assessment for Neuropsychological Rehabilitation Planning

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James F. Malec
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4
ASSESSMENT FOR
NEUROPSYCHOLOGICAL
REHABILITATION PLANNING
James F. Malec

Begin with the end in mind

Because it affects the organ that regulates all other bodily systems and creates the person, acquired
brain injury (ABI) can affect all aspects of the person. For this reason, rehabilitation is best planned
based on a very comprehensive, holistic assessment of the person’s strengths and limitations as well
as the social and physical environment in which they live. More specifically, a comprehensive
assessment discovers who the person was before the injury (pre-injury history); current medical status
including prior injuries; family and social context; educational and vocational history and aspirations;
current and past history of psychopathology and substance use; details of the injury including
associated non-brain injuries; and current strengths and weaknesses in cognitive, emotional,
behavioural and physical functioning. A comprehensive assessment evaluates the degree and
consistency with which the person understands and appreciates the problems arising from their
injury and how these problems may interfere with their goals, that is, their self-awareness. The
assistance or interference that they may receive from family and friends and other community
resources in pursuing their goals is also assessed. The goal for most individuals applying for
neuropsychological rehabilitation services is a return to full participation in family and community
life. A comprehensive assessment details all potential personal and environmental resources that may
contribute to and barriers that may interfere with the pursuit of this overarching goal.
The most effective rehabilitation planning typically combines elements of the medical model with
those of the social model of disability. The medical model is based on determining an accurate diagnosis
and prescribing treatment to cure or manage symptoms of the diagnosed disorder. As such, the
emphasis of the medical model for rehabilitation is to identify and remediate causes of disability that
reside in the individual. The social model, in contrast, indicates that the primary cause of disability is
environmental. Originators of the social model, who were living with spinal cord injuries (The
Union of the Physically Impaired against Segregation and The Disability Alliance Fundamental
Principles of Disability, 1975), pointed out that the largest portion of their disabilities could be resolved
with appropriate modifications to the physical environment (e.g. ramps or lifts instead of stairs,
counters at chair level rather than at standing level). In applying the social model in ABI, one must
consider not only the physical but also the social environment. Although appropriate modifications
to the physical environment (e.g. moderation of lighting and noise levels) will also reduce disability
for some people with ABI, implementation of a social model of rehabilitation will also very likely

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Assessment for rehabilitation planning

include accommodations and compensatory devices to assist the individual in managing cognitive
demands of the environment, as well as counselling and education with key people in the person’s
environment, to improve social acceptance and support emotional self-management.
A successful rehabilitation programme will include behavioural and/or pharmacological
interventions to reduce the disabling conditions within the individual (medical model). However,
simply reducing disability is not a sufficient end goal of rehabilitation. The assumption of such an
approach restricted to the medical model is that reduction or elimination of disability will lead to
improved function and community participation. That assumption is often proved false by factors
outside the individual that create barriers to their function and community re-entry, for example, the
prejudices or fears of employers or colleagues when a history of ABI is known, or conversely, the
over-protectiveness of friends and family. Furthermore, while we may not care to characterise them
as ‘disabilities’, most of us function in life despite specific limitations. The entire array of limitations
or disabilities with which a given individual presents for rehabilitation does not necessarily have to
be remediated for them to return to a satisfying lifestyle. As Stephen Covey (2003) suggested for
general success in life, successful rehabilitation should ‘begin with the end in mind’. Broadly stated,
the end goal for most rehabilitation participants is a satisfying return to family and community life.
In the individual case, once this end goal is more specifically and clearly stated, rehabilitation can be
planned toward its achievement that aims to reduce barriers, including both personal disabilities and
environmental factors and to capitalise on personal strengths and environmental resources.

Components of a comprehensive assessment

Pre-injury history
Pre-existing medical conditions, particularly those of a chronic nature, can significantly impact
rehabilitation planning and goals. Although some funders may insist that they are not responsible for
rehabilitating pre-existing conditions, these conditions are inextricably intertwined with the effects
of ABI and must be considered in rehabilitation planning. For instance, a rehabilitation goal may be
implementing a plan to assist a participant with diabetes to remember to regularly measure and
record their blood sugar and self-administer insulin. Prior brain injuries as well as other pre-existing
brain disorders are also of particular importance in acquiring a medical history for rehabilitation. A
prior history of psychiatric disorder or substance abuse increases the risk that the participant will
experience these conditions after the injury (Fann, Hart, and Schomer, 2009). Although a thorough
discussion of personality theory and assessment is well beyond the scope of this chapter, an appraisal
of the participant’s pre-injury personality will be very helpful in anticipating reactions to the demands
and stresses imposed by their injury and the rehabilitation process. While in some cases ABI may
change the person’s personality, more often ABI makes them ‘more like who they are’ (i.e. leads to
disinhibition and an exaggeration of pre-injury personality traits).
Knowledge of the participant’s prior educational and vocational history and aspirations is critical
for negotiating end goals for community re-integration. Those with a record of high achievement
prior to injury may have more difficulty accepting limitations imposed by the injury. Involved and
supportive family members can be extremely important allies in the rehabilitation process; conversely,
a dysfunctional family can be an equally significant impediment to successful rehabilitation. One-
quarter to one-third of families enter ABI rehabilitation with some degree of dysfunction (Sander et
al., 2003). Knowledge of pre-injury family functioning and the participant’s relationship to their
family will assist in engaging (or deciding not to engage) families in the rehabilitation process and in
planning for appropriate intervention with families who may benefit from family counselling or
therapy. Throughout this chapter ‘family’ is used to refer to the network of close others with whom
the person with ABI lived or was most closely associated. In most cases, this will be the person’s

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biological family but, in some cases, may include close others with whom the person with ABI has
no biological relationship. Assessment of the participant’s family will be discussed in greater detail
later in this chapter.

Injury parameters
Although the severity of the initial ABI is not perfectly correlated with the degree of disability or
sequelae that the person will experience, knowledge of injury severity provides some indication of
the extent and persistence of disabling conditions that may result from the injury. In traumatic
injuries, injury severity is estimated by the Glasgow Coma Scale, length of post-traumatic amnesia
(PTA) and loss of consciousness, and time to follow commands (Brown et al., 2005). Extent and
location of brain damage apparent on CT or MRI scans will corroborate or, in some cases, challenge
a behavioural assessment of disabilities in both traumatic and non-traumatic ABI. A normal CT scan
is not uncommon among individuals with mild or even moderate traumatic ABI, despite other
indications of a significant injury and persistent disabilities or other sequelae. MRI scanning is more
sensitive to intracranial abnormalities (Wintermark et al., 2015) but may also not clearly indicate the
degree or nature of impairment resulting from the injury. Conversely, some individuals demonstrate
remarkable functional recovery despite neuroimaging evidence of significant structural brain damage.

Associated injuries and comorbidities

Disability may occur not only from the ABI but from other injuries and comorbid conditions. For
example, Brown and colleagues (2014) reported that premature mortality after traumatic ABI is
more likely due to associated non-brain injuries. Depression, pain, sleep disturbance, and fatigue are
common among people with ABI (Bushnik, Englander, and Wright, 2008). Such conditions may
result from the ABI, associated injuries – or psychological reaction to injury. Whatever the cause,
such comorbid conditions can interfere markedly with rehabilitation engagement and success and
therefore require evaluation and treatment.

Physical limitations
Physical disabilities interfering with ambulation or use of hands or with sensory processes (vision,
hearing, taste, smell) should be assessed. Complete characterisation of physical disabilities often
requires additional assessment by experts in physiotherapy, occupational therapy, audiology,
optometry and ophthalmology, and neurology. Balance and vestibular problems are also not
infrequent after ABI and may require specialty evaluation and treatment.

Cognitive functioning
Cognitive abilities are commonly affected by ABI. A neuropsychometric evaluation will describe the
profile of strengths and weaknesses in overall intelligence, attention, memory, language and
visuospatial abilities, as well as executive and higher-order (e.g. reasoning, planning) cognitive
abilities. The term neuropsychometric is used to distinguish the quantitative measurement portion of a
neuropsychological evaluation from other aspects of that evaluation. A comprehensive
neuropsychological evaluation will also assess many of the areas described in this chapter through
clinical interview (Hsu et al., 2013) and often includes standardised assessments of psychological and
personality functioning, which will be discussed later in this chapter. Table 4.1 describes major
domains typically included in a cognitive neuropsychometric evaluation and examples of tests that
may be used to assess these ability areas. In this chapter, examples of specific tests and measures are

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provided that may contribute to the assessment of functional and impairment domains. However,
there are typically a number of other valid options besides those suggested here for tests or measures
to assist in evaluation in a specific domain. Lezak and associates (2012) describe tests listed in Table
4.1 in greater detail, as well as many other options for the assessment of cognitive and psychological
domains. Tate (2010) provides comprehensive coverage of available measures in other key domains
relevant to ABI rehabilitation (see Table 4.2). Referenced sources that provide more information
about specific tests mentioned in the remainder of this chapter can be found in Tables 4.1 and 4.2.
Few neuropsychometric tests purely measure the domain for which they were designed. For
example, performance on measures of complex attention, such as the Trailmaking Test, also relies on
executive cognitive functions and working memory. Performance on measures of visuospatial
abilities, such as matrix reasoning and block design, also depends on higher-order reasoning abilities.
For this reason, interpretation of results of a neuropsychometric profile is both an art and a science
and is best done by a neuropsychologist with specific postdoctoral training in neuropsychological test
interpretation.
When conducted for rehabilitation planning purposes, the neuropsychometric evaluation is
primarily concerned with understanding the types and degree of cognitive impairment resulting
from a diagnosed ABI. Just as important is an assessment of the person’s functional cognitive abilities,
that is, the degree to which cognitive impairments apparent on neuropsychometric testing interfere

Table 4.1  Cognitive domains and example measures

Cognitive domain Standardised test examples For detailed information, see

Lezak et al. (2012)
Verbal Intelligence (remote, Wechsler Adult Intelligence Scales (WAIS) pp. 713–25
crystallised memory) Verbal-Comprehension Index (Vocabulary,
Similarities, Information)
Reading Word Recognition Wide Range Achievement Test (WRAT- p. 563
IV) Reading (also may be used to estimate
preinjury verbal intelligence)
Non-verbal Intelligence WAIS Perceptual Reasoning Index (Block pp. 713–25
(visuospatial abilities) Design, Matrix Reasoning, Visual Puzzles)
Verbal Memory Weschler Memory Scales (WMS) Logical pp. 522–31
Memory I and II pp. 471–8
Auditory Verbal Learning Test (AVLT)
Visuospatial Memory WMS Visual Reproduction I and II pp. 522–31
Attention, WAIS Digit Span and Letter-Number pp. 713–25
Concentration, Sequencing
Working Memory Stroop Test p. 417
Trailmaking Test pp. 422–25
Language Abilities: Receptive Token Test pp. 557–60
Expressive Boston Naming Test pp. 549–51
Word finding Controlled Oral Word Association Test pp. 694–5
Word Fluency pp. 695–6
Higher-order Abilities DKEFS Card Sort pp. 706–8; 643–4;
(reasoning, planning) DKEFS Tower Test 678–9; 628–9
DKEFS Twenty Questions
Category Test pp. 624–7
Performance Effort Test of Memory Malingering (TOMM)§ pp. 849–50

§ Despite its name, the TOMM is more accurately described as a measure of performance effort, which may be
affected by physical and psychological factors other than conscious malingering (Locke et al., 2008).

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James F. Malec

Table 4.2  Functional domains and example measures

Domain Assessment tool examples For detailed information

Functional Memory Rivermead Behavioural Memory Test-3
Everyday Memory Questionnaire
Executive Functioning Dysexecutive Questionnaire (DEX)
Frontal Systems Behavior Scale (FrSBe)
Emotional Status PHQ-9
GAD-7
TBIQol
Personality/ Minnesota Multiphasic Personality Inventory
Psychopathology (MMPI)
Personality Assessment Inventory (PAI)
Self-awareness Awareness Questionnaire
Self-awareness of Deficits Interview
Substance Abuse CAGE questions; Substance Abuse Subtle
Screening Inventory (SASSI-3)
Family Functioning General Functioning Index of Family
Assessment Device (FAD)
Community Participation Participation Assessment with Recombined
Tools-Objective (PART-O)
Mayo-Portland Adaptability Inventory
(MPAI-4) Participation Index
Global Functioning Mayo-Portland Adaptability Inventory
(MPAI-4)
(Wilson, 2009, pp. 46–8
(Tate, 2010, pp. 235–9)
(Tate, 2010, pp. 197–9)
(Tate, 2010, pp. 316–18)
(Kroenke and Spitzer, 2002)
(Fann et al., 2005)
(Spitzer et al., 2006)
(Tulsky, 2011)
(Lezak et al., 2012, pp. 858–61)
(Lezak et al., 2012, p. 861)
(Tate, 2010, pp. 258–61)
(Tate, 2010, pp. 266–70)
(Ewing, 1984)
(Ashman et al., 2004)
(Epstein, Baldwin and Bishop,
1983)
(Bogner et al., 2013)
(Malec, 2004)
(Tate, 2010, pp. 643–6)
(Malec and Lezak, 2008)

with the person’s function in life given their work, lifestyle, and the internal or external compensation
techniques that they have developed. The Rivermead Behavioural Memory Test-3 and Everyday
Memory Questionnaire are examples of tools that may be helpful in a functional cognitive evaluation.

Emotional status and psychopathology

Depression, anxiety and irritability are common after ABI, they contribute to overall disability and
interfere with rehabilitation. The Patient Health Questionnaire 9-item Depression Scale (PHQ9),
Generalized Anxiety Disorder 7-item Scale (GAD) and Traumatic Brain Injury Quality of Life
(TBIQoL) measures can be helpful in screening for these types of disorders and monitoring the
effectiveness of treatment. Evaluation of more severe psychopathology or personality disturbance
will require evaluation by a clinical psychologist, neuropsychologist or neuropsychiatrist who is well
versed in both psychopathology and the effects of ABI. Such an evaluation may include standardised
measures, such as the Minnesota Multiphasic Personality Inventory (MMPI) or the Personality
Assessment Inventory (PAI).

Behavioural self-management and self-awareness

In addition to or associated with emotional disorders after ABI, behavioural disturbances are also
common. These may be due to behavioural disinhibition or, conversely, to lack of responsiveness
(abulia), and are often associated with impairment of cognitive executive functions. Measures like

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the Dysexecutive Questionnaire (DEX) or Frontal System Behavior Scale (FrSBe) may be helpful in
the assessment of such behavioural disturbances that represent the functional effects of impaired
cognitive executive abilities. However, in cases in which the behavioural disturbance is relatively
idiosyncratic, an applied behavioural analysis approach (Karol, 2013) to specifying the undesirable
behaviour(s) and tracking the success of behavioural intervention is most appropriate.
Self-awareness is also often impaired as a result of severe ABI. In cases of severely impaired self-
awareness, the participant may not be able to recognise the impairments that have resulted from the
ABI. More commonly, persons with ABI are able to report their impairments but cannot conceptualise
how these impairments will interfere with their return to valued activities. A separate interview with
a close other is typically very informative regarding such ‘blind spots’ in the participant’s self-
awareness. The Awareness Questionnaire provides a tool for screening for impaired self-awareness
and the Self-Awareness of Deficits Interview (SADI) offers a more probing assessment.
Problematic substance use is difficult to assess in any population because of the tendency toward
denial by those with problematic substance use. The CAGE questions have been shown to be
effective in screening for possible alcohol abuse and the Substance Abuse Subtle Screening Inventory
(SASSI-3) for other drug abuse. The separate interview with a close other may also raise concerns
about substance use that the person with ABI denies; however, co-dependency and collaborative
denial is not uncommon among those close to individuals with chronic substance abuse problems.

Interpersonal and social skills

Pragmatic communication skills, such as non-verbal communication, turn-taking, and appropriate
initiation or restriction of verbalisations, are often impaired by ABI. Other more complex social
skills, like affect recognition and empathy, may also be affected (Neumann et al., 2014). These types
of problems often present the most significant barriers to successful re-integration into family and
community life for the person with ABI, and in most cases will be apparent in an extended interview
and interactions with the person with ABI and through the separate interview with a close other.
The assessment and treatment of social cognition and communication disorders is described in greater
detail in Chapters 21 and 22.

Social and family adjustment

Support from close others is important to encourage rehabilitation participants and to facilitate their
engagement in the rehabilitation process as well as in following through with therapeutic activities
outside the treatment facility. For this reason, an evaluation of the dynamics of the participant’s
family and close others is useful to get a sense of whether interactions between the participant and
these close others will have a positive or negative impact on the participant’s progress in rehabilitation.
Assessment of the family (or in some cases, a network of close others that serves as the participant’s
‘family’) can occur as part of interactions and separate interviews with them. As mentioned previously,
one-quarter to one-third of families are in some degree of distress at the time that one of their
members sustains a traumatic ABI (Sander et al., 2003). If family dynamics are severely stressed or
pathological, engagement of the family in the rehabilitation process may be challenging or have
negative consequences. In rare cases in which there is severe pathology within the family, the
participant may be best served by being assisted in extricating him or herself from the family
environment. More commonly, families or networks of close others that are significantly stressed by
the injury and rehabilitation process can be helped through education, training in basic coping skills,
and involvement in family and rehabilitation therapy to better support the participant. Hence, the
family assessment is essentially a triage to determine which families are: (1) severely disturbed and
need intensive treatment or separation from the participant; (2) significantly stressed and require a

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more intensive coping skills intervention; or (3) experiencing normal stress and may benefit from
involvement in therapy and education about ABI with reinforcement of basic coping skills.
Although the family assessment is typically qualitative and based on multiple interactions of family
members with various rehabilitation team members, the General Index of the Family Assessment
Device (FAD) provides a screening tool for assessing the level of distress within a family or network
of close others. From a qualitative perspective, assessment of the participant’s family and more general
social environment identifies both the potential supports and the barriers for successful community
re-integration. Who are the people who will be the participant’s strongest and most consistent allies
in this process? Who does the participant respect the most and thus will be the strongest source of
encouragement? Which friends will be their allies in re-entry into their former social milieu? Who
may have biases against people with disabilities or brain injuries? Were the participant’s relationships
with former employers or teachers positive or negative? Will these former employers or teachers be
their allies or obstacles to future success? Further discussion of the role of families can be found in
Chapter 29.

Community participation
Considering the principle of ‘beginning with the end in mind’, the participant’s current and desired
involvement in family and community activities is an essential part of the rehabilitation evaluation.
Instruments like the Participation Assessment from Recombined Tools-Objective (PART-O) or the
Participation Index of the Mayo-Portland Adaptability Inventory (MPAI-4) provide quantitative tools
for assessing current status and progress in this area. However, perhaps more important during the
initial evaluation is an assessment of the participant’s desired participation in the various domains of
community life since these form the basis for the end goal of rehabilitation. Because of impaired self-
awareness, participants’ (or their families’) expectations for community participation may not be
realistic at the time of the initial evaluation. However, in working toward their desired level of
participation through rehabilitation, self-awareness can be developed and more realistic goals set. Basic
domains of participation include the (1) independent living, including participants’ ability to manage
their self-care, cooking, shopping, cleaning, home repair, and other aspects of living independently in
the community; (2) involvement in social and recreational activities; (3) involvement in productive
activities, such as paid or unpaid employment, education, or managing a household; (4) managing
money, that is, both smaller sums involved in shopping and everyday monetary transactions as well as
managing savings, investments and other larger sums of money over the long term; and (5)
transportation, that is, the ability to travel longer distances in the environment through the use of a
private motor vehicle, other forms of personal transportation (bicycle, horseback in some locales), or
public transportation. In each of these areas, an appraisal should be made of the degree of supervision
or assistance the person needs and an estimation of what might be a realistic goal for more independent
functioning. As is true in most evaluation domains, what constitutes a realistic goal will become
clearer to both therapists and participants as they proceed through the rehabilitation process.
As in the assessment of the participant’s social environment, planning for community re-entry will
involve identification of barriers and supports for this process. Was the participant associated with
groups (e.g. church groups, social clubs) that might be eager to re-engage with the participant or help
in concrete ways like transportation? Is accessible public transport available? What services (e.g.
vocational, financial, independent living) are available through the government or community groups?
While it is unrealistic to think that a thorough assessment of social and community resources and
barriers can be accomplished in an initial evaluation, identifying and managing these factors is often
critical to the long-term success of rehabilitation. Consequently, evaluation of environmental factors
continues throughout the rehabilitation process and becomes increasingly important in planning for
discharge and maintenance in the community.

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Translating a comprehensive assessment into a rehabilitation plan

The primary purpose of a systematic, standardised, comprehensive approach to assessment is to
develop an effective rehabilitation treatment plan. This should also be done systematically. One
method that is familiar to me to illustrate this process involves referencing results of the Mayo-
Portland Adaptability Inventory (MPAI-4) to establish interventions and goals for identified
problems. The MPAI-4 was designed as an evaluation tool and outcome measure for post-hospital
brain injury rehabilitation (Malec and Lezak, 2008). As such, it provides ratings by the rehabilitation
team or evaluator of the 30 most typical functions and activities affected by ABI. Five additional
items identify comorbidities (alcohol and drug abuse, legal problems, comorbid physical disabling
conditions and comorbid cognitive disabling conditions) that should also be considered in
rehabilitation planning. The MPAI-4 can also be completed independently by individuals with ABI
and their close others to assess their awareness and agreement with the rehabilitation team in
identifying problem areas. The MPAI-4 is used here to illustrate the process of translating a systematic,
standardised, comprehensive assessment into a rehabilitation plan. However, a similar process can be
developed using centre-specific assessment protocols or other comprehensive assessment tools.
Table 4.3 illustrates the process for an individual who is very severely disabled after a traumatic
ABI. To provide a robust case example and protect confidentiality, this illustrative case combines
features of several individuals with whom I have worked. A typical history of an individual with this
severity of disability following a traumatic ABI is as follows:

The patient is a 22-year-old Caucasian man who experienced a severe brain injury in a
motorcycle accident about five years ago. He sustained a left lower extremity fracture in
the same accident. His brain injury was severe with a Glasgow Coma Scale of 5 in the
Emergency Trauma Centre, post-traumatic amnesia of approximately three months, and
an initial CT scan showing multiple contusions and intracerebral haemorrhages and
swelling. He is post craniectomy and has diplopia corrected with prism glasses which he
does not wear consistently. He also has a bilateral hearing loss corrected with hearing aids
but he does not wear these consistently. He is on an antidepressant but no other medications.
He was in good health at the time of the injury with no prior history of significant medical
conditions, psychiatric or substance abuse disorders. He is unmarried and a high school
graduate who worked as a stocker in a discount store prior to injury. Currently he lives in
supervised residential settings since his acute hospitalisation and inpatient rehabilitation. He
is one of six children. His family lives at some distance and visits two or three times a year.

Following a comprehensive evaluation and rating on the MPAI-4, the process of linking significant
problem areas to interventions and goals is relatively straightforward, as illustrated in Table 4.3. The
current status, using the MPAI-4 rating scales, is identified. The proposed intervention is added, and
finally, the goal, again using the MPAI-4 rating scale, is projected. While MPAI-4 ratings provide a
relatively comprehensive assessment as recommended in this chapter, additional problems not
covered by these items may also be added in a similar manner. Following the overarching principle
‘begin with the end in mind’, not every identified problem requires intervention. If little progress in
a particular area is expected, or if the progress anticipated would make little difference in increasing
the participant’s reintegration into family and community life, no intervention is proposed.
The rehabilitation team should be agreed among themselves about the basic elements of the
treatment plan before reviewing the plan with the participant and their close others. Once the team
has reached consensus, the treatment plan is presented to the participant and their close others,
discussed and, to the degree that it is appropriate, revised with their input. This review includes
education about the identified problems and the rationale for intervention. At times, the rehabilitation

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Table 4.3  Translating assessment into a treatment plan: illustrative case example

Problem area Current status Intervention Goal

Mobility Moderate problem; interferes Training in electric Mild problem; interferes
with activities 25–75% of wheelchair use; behavioural with activities 5–24% of the
the time management to reduce time
impulsive behaviours
Use of hands Moderate problem; interferes None; medical evaluation for No further improvement
with activities 25–75% of spasticity to reduce pain expected
the time
Vision Moderate problem; interferes Prompts/stimulus control for Mild problem; interferes
with activities 25–75% of more consistent use of prism with activities 5–24% of the
the time lenses time
Hearing Mild problem; interferes Prompting/reinforcement Mild problem but does not
with activities 5–24% of the to continue to wear hearing interfere with activities
time; use of hearing aids aids
Motor speech Moderate problem; interferes Speech/Language Therapy Mild problem; interferes
with activities 25–75% of evaluation; prompting/ with activities 5–24% of the
the time stimulus control to slow rate time
and improve articulation
Verbal Mild problem; interferes Speech/Language Therapy No further improvement
communication with activities 5–24% of the evaluation; probable stable expected
time mild expressive aphasia
Non-verbal Severe problem; interferes Behavioural management Mild problem; interferes
and pragmatic with activities more than programme to reduce with activities 5–24% of the
communication 75% of the time swearing and tangentiality time
skills
Fund of Mild problem; interferes None No further improvement
information with activities 5–24% of the expected
time
Visuospatial Mild problem; interferes None No further improvement
with activities 5–24% of the expected
time
Impaired novel Severe problem; interferes Behavioural management Mild problem; interferes
problem-solving with activities more than programme to reduce with activities 5–24% of the
75% of the time impulsive behaviour, increase time
requesting advice
Impaired Severe problem; interferes Medical evaluation for Mild problem; interferes
attention with activities more than potential treatment with with activities 5–24% of the
75% of the time stimulant medication; time
Attention Process Training
Impaired Severe problem; interferes System of external prompts Mild problem; interferes
memory with activities more than for activities; schedule on with activities 5–24% of the
75% of the time wheelchair time
Depression Mild problem; interferes Review medications; treat Mild problem but does not
with activities 5–24% of the in context of aggression; interfere with activities
time behaviour plan to reduce
negative self-statements
Irritability/ Severe problem; interferes Review medications; Mild problem but does not
aggression with activities more than behavioural management interfere with activities
75% of the time programme;
pain management

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Problem area Current status Intervention Goal

Impaired self- Severe problem; interferes Behavioural management Mild problem; interferes
awareness with activities more than programme to reduce impact with activities 5–24% of the
75% of the time of impaired self-awareness on time
activities
Social interaction Severe problem; interferes Behavioural management Mild problem; interferes
with activities more than programme with activities 5–24% of the
75% of the time time
Family Mild problem; interferes Stable if not optimal family No change expected
relationships with activities 5–24% of the situation; maintain regular
time contact with family
Pain Moderate problem; Medical evaluation for Mild problem but does not
interferes with activities spasticity treatment; interfere with activities
25–75% of the time redirection, non-
reinforcement of pain
behaviours
Initiation Mild problem; interferes System of prompts and cues Mild problem but does not
with activities 5–24% of the interfere with activities
time
Social contact No or rare involvement Regularly scheduled social Mild difficulty in social
with others (less than activities; behavioural situations but maintains
25% of normal treatment to reduce unsocial normal involvement with
interaction for age) behaviours others
Recreational No or rare involvement Regularly scheduled Mild difficulty in social
activities with others (less than recreational activities; situations but maintains
25% of normal behavioural treatment of normal involvement with
interaction for age) disruptive behaviours others
Self-care Requires moderate assistance System of prompts and cues; Mild difficulty, occasional
(25–75% of the time) behavioural management of omissions, slow
disruptive behaviours
Residence Requires assistance more No specific intervention Will continue to require
(independent than 75% of the time supervised, supportive
living); environment
transportation
Paid Unemployed Involve in sheltered work as Sheltered work
employment behavioural problems begin
to resolve
Money Requires assistance more No specific intervention; Will continue to require
management than 75% of the time begin discussion of other extensive supervision
guardianship with parents

team may disagree with the participant and/or close others about the need or type of intervention in
some areas. These areas of disagreement should be saved for further discussion that may extend for
several future sessions and will involve negotiating priorities for intervention with the participant and
their close others. Particularly in cases where awareness of deficits or their effects on activities is
limited for participant and/or close others, the rehabilitation team may need to start interventions in
areas where all agree progress can be made and continue to negotiate additional goals as awareness
improves.
As rehabilitation proceeds, assessment continues and interventions are changed or modified in
areas where the initial intervention does not appear to be effective. Progress may be monitored using
specific measures or behavioural metrics. Goal attainment scaling (GAS) provides another method

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James F. Malec

Table 4.4  Examples of GAS

Irritability/aggression
Goal: Participant responds to stress or challenges without angry behaviours.
Much better than expected outcome: Under stress, participant seeks assistance in addressing stressor with
minimal evidence of anger without prompting the majority of the time.
Better than expected outcome: Under stress, participant seeks assistance in addressing stressor with
minimal evidence of anger; the majority of the time external prompting and reinforcement is required.
Expected outcome: Under stress, participant is visibly angry but shouts, curses or strikes wheelchair less
than 5 per cent of the time with external prompting and reinforcement.
Less than expected outcome: Participant shouts, curses or strikes wheelchair under stress about 75–80 per
cent of the time.
Much less than expected outcome: Participant shouts, curses or strikes wheelchair under stress almost all
the time.
Impaired self-awareness
Goal: Participant’s awareness of his behavioural problems is sufficient to support his engagement
in rehabilitation interventions.
Much better than expected outcome: Participant consistently acknowledges need for rehabilitation and
consistently participates in rehabilitation therapies.
Better than expected outcome: Participant acknowledges need for rehabilitation most of the time and
withdraws or becomes angry during rehabilitation therapies less than 5 per cent of the time.
Expected outcome: Participant acknowledges need for rehabilitation intermittently and withdraws or
becomes angry during rehabilitation therapies less than 25 per cent of the time.
Less than expected outcome: Participant does not acknowledge need for rehabilitation and withdraws or
becomes angry during rehabilitation therapies about 75–80 per cent of the time.
Much less than expected outcome: Participant does not acknowledge need for rehabilitation and
withdraws or becomes angry during rehabilitation therapies almost all the time.

for goal-setting and tracking progress for highly individualised rehabilitation goals (Malec, 1999).
GAS goals should be SMART (specific, meaningful, action-oriented, realistic and timely) and
identify five levels of goal achievement. A ‘less than expected outcome’ usually represents status on
admission and a ‘much less than expected outcome’ represents further decline. The ‘expected
outcome’ identifies the minimal clinically important change toward positive goal achievement and is
an acceptable outcome. Two additional levels (‘better than expected outcome’ and ‘much better
than expected outcome’) represent outstanding progress toward the stated goal. Table 4.4 provides
an illustration of GAS for areas believed to be of key importance for the case illustrated in Table 4.3.

Final thoughts
Physiological and psychological processes are highly interconnected in human beings and problems
in one often contribute to problems in another. This is the rationale behind completing a
comprehensive evaluation to address problems systematically in planning brain injury rehabilitation.
This chapter has also emphasised that brain injury rehabilitation is not just about addressing problems
but rather addressing issues and building on strengths with an eye to the end goal of satisfying
participation in family and community life for the rehabilitation participant.
Ideally a comprehensive evaluation is completed by a rehabilitation team. However, in some
settings, an initial evaluation may be started by an individual provider and become more
comprehensive as priority areas for intervention are identified. Initial evaluations rarely provide the
definitive assessment of an individual and such assessments must be modified over time with
increasing experience and understanding of the individual case.
The use of standardised measures has been emphasised in this chapter and such measures will
increase the reliability of assessment and may provide a means for monitoring progress in specific
areas. The use of standardised measures to screen for problems that are very common after ABI, such

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Assessment for rehabilitation planning

as depression, may also increase the efficiency of the initial evaluation. On the other hand, it is
impractical to evaluate every potentially relevant feature of participants and their environments using
standardised measures. More typically, rehabilitation evaluations start with interviews of the
participant and close others with the administration of standardised measures in areas of particular
concern or significance. In short, while a comprehensive, holistic approach to evaluation and
treatment planning is highly recommended in brain injury rehabilitation, this approach can be
applied flexibly depending on resources and limitations within particular treatment settings.

Acknowledgement
The writing of this chapter was accomplished with the support of the Fürst Donnersmarck Foundation
2015 Research Award.

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