Miami University Speech and Hearing Clinic Cognitive-Linguistic Evaluation Name: Brittany Spears Address: 4601 Victory Parkway Cincinnati, OH 45229 Telephone: 513-583-9418

Date of Evaluation: 3/12/14 Diagnosis: TBI: Rancho 9 Date of Birth: 9/23/1990

Referred By: Dr. Timberlake, on 3/12/14 for “Cognitive-Linguistic Evaluation.” Background Information Ms. Spears, a 23-year-old female, was seen at the Miami University Speech and Hearing Clinic on 3/12/14 for a cognitive-linguistic evaluation. She was accompanied to the evaluation by her mother who supplied the following medical history. Ms. Spears provided her own communication and social history as well as the information required for her discharge home from the hospital. The purpose of the evaluation was to determine the patient’s current communication and cognitive strengths and weaknesses and determine the patient's level of function. Recommendations will be made for outpatient therapy. Medical History: Ms. Spears sustained a TBI on 2/12/14. Ms. Spears reported experiencing mild disorientation and confusion after a 10 minute period of unconsciousness following a MVA. A CT scan showed focal damage to the frontal lobe with a minor hemorrhage on Ms. Spears' left anterior frontal lobe. Ms. Spears' physical ability is WFL with the exception of a broken left arm Ms. Spears experienced post-traumatic amnesia lasting less than 24 hours and showed quick improvements thereafter. Dr. Timberlake's report stated that Ms. Spears' cognitive and behavioral characteristics were indicative of a Rancho Level 7 following the accident, but progressed to a Rancho Level 9 after three weeks of intensive inpatient therapy. According to her mother, Ms. Spears received inpatient rehabilitation services (PT, OT, and ST) at the University of Cincinnati Medical Center from 2/15/14 through 3/9/14. Ms. Spears was then discharged to her home in the care of her mother. Ms. Spears reported being cooperative in all therapy sessions and reported having a hard time focusing in a distracting environment. Her mother reported that Ms. Spears has no notable past medical history. Ms. Spears' sight is WNL and does not wear glasses; her hearing is WFL. Current medications include over the counter aspirin for pain. History of Communication Problem: As of March 2014, the information provided by Ms. Spears' inpatient speech therapist, Mrs. Aguilera, indicated moderate to maximum cognitive improvement. Mrs. Aguilera recommended reducing distractions during attention tasks and requesting assistance when needed upon discharge. Early in inpatient rehabilitation, Ms. Spears presented with moderate attention, memory, and executive function deficits. Currently, she is exhibiting mild deficits in attention and self-awareness, and executive functioning. Ms. Spears' primary areas of deficit are attention and executive functioning. Ms. Spears reported that she is aware that she was in a MVA and was able to explain premorbid strengths (i.e. studying in distracting environments such as Starbucks) and weaknesses in specific

areas. Ms. Spears reported moderate frustration when trying to study in a distracting environment and unable to comprehend the content like she used to. She reported having difficulty "reading past one page of a book without getting distracted by the music coming from her brother's room and taking too long to finish homework." Ms. Spears' mother's primary concern is that her daughter "can't seem to focus and needs to go back to school in May." She further reported that Ms. Spears occasionally suffers from sleep disturbances and becomes agitated when she can't complete a task (i.e. homework) in a short amount of time like she used to. Her mother reported that she has been encouraging Ms. Spears to "read her textbooks so she can pick up where she left off when she goes back to school in May, but is worried that she may not be able to live and function independently." Ms. Spears is interested in continuing outpatient therapy and work towards getting back to school in 2 months. Social/Vocational and Educational History: Ms. Spears is single and lived in Berkeley, California, prior to her accident. She is currently living with her mother, Meryl, and her brother, Justin, in Cincinnati, Ohio. She received a bachelor's degree in Performing Arts from the University of California, Los Angeles (UCLA), and began graduate school for Performance Studies at the University of California, Berkeley (UC Berkley), last fall. Prior to the MVA, Ms. Spears enjoyed singing, performing at local bars on the weekends, reading, and doing Pilates. She drove herself around the city, had a large group of friends, and was a very responsible student. She expressed an interest in getting back to school and performing like she did before. She is currently able to read in a quiet environment and can perform simple ADLs independently (i.e. washing dishes, putting on makeup, and getting dressed). Ms. Spears' mother, Meryl Streep owns a small clothing boutique in Cincinnati and works part time. Ms. Streep is a single mother and has raised Ms. Spears and her brother on her own for 18 years. Ms. Streep is healthy and has decided to manage her business from home since her daughter's discharge from the hospital. Ms. Streep is able to drive Ms. Spears to all her therapy sessions.

Evaluation Results Oral Peripheral Examination Upon examination, Ms. Spears presented with no signs of facial weakness; facial sensation was intact. Lingual and labial strength, coordination, and range of motion appeared to be WFL. Voice: Ms. Spears resonance, pitch range, volume, and voicing appeared WFL for her age and gender. Fluency: Ms. Spears rate of fluency was noted to be WFL. Swallowing: Ms. Spears' swallowing appeared to be WFL.

The evaluation consisted of formal and informal assessments of Ms. Spears' cognitive abilities including attention, memory, and executive functioning. Subtests of the Scales of Cognitive Ability for Traumatic Brain Injury (SCATBI) were administered. Results of the subtests were inconsistent due to deficits in attention and executive function. The results are as follows: SCATBI Perception and Discrimination Scale/Testlet 1. Sound Recognition 2. Shape Recognition 3. Word Recognition (no distraction) 4. Word Recognition (with distraction) 5. Color Discrimination 6. Shape Discrimination 7. Size Discrimination 8. Discrimination of Color, Shape, Size 9. Discrimination of Pictured Objects 10. Auditory Discrimination (real words) 11. Auditory Discrimination (nonsense) Sum of Testlet Scores

Raw Score 5 3 7 6 3 3 3 12 6 4 5 57

Scale/Testlet

Raw Score

1. Premorbid Questions 2. Postmorbid Questions

6 14 20

Organization Scale/Testlet 1. Identifying Pictured Categories 2. Identifying Pictured Category Members 3. Word Associations (word categories) 4. Sequencing Objects (size) 5. Sequencing Words (alphabetical) 6. Sequencing Events (time of year) 7. Sequencing Events (pictured task steps)

3 30

Recall Scale/Testlet 1. Memory for Graphic Elements 2. Naming Pictures (word retrieval) 3. Immediate Recall of Word Strings 4. Delayed Recall of Word Strings 5. Cues Recall of Words 6. Cued Recall of Words in Discourse 7. Word Generation 8. Immediate Recall of Oral Directions 9. Recall of Oral Paragraphs Sum of Testlet Scores

Raw Score 6 6 4 3 6 3 8 6 8 50

Reasoning

Orientation

Sum of Testlet Scores

8. Sequencing Events (recall task steps) Sum of Testlet Scores

Raw Score 8 6 5 2 2 2 2

Scale/Testlet 1. Figurative Reasoning: Matrix: Analogies 2. Convergent Thinking: Central Theme 3. Deductive Reasoning: Elimination 4. Inductive Reasoning: Opposites 5. Inductive Reasoning: Analogies 6. Divergent Thinking: Homographs 7. Divergent Thinking: Idioms 8. Divergent Thinking: Proverbs 9. Divergent Thinking: Verbal Absurdities 10. Multiprocess Reasoning: Task Insight 11. Multiprocess Reasoning: Analysis Sum of Testlet Scores

Raw Score 8 3 2 4 5 2 2 4 2 6 2 44

Summary Raw Score Percentile Rank Standard Score Composites Lower Function Higher Function SCATBI Total

Per/Disc 57 90 119 Per/Disc SS 119 113

Orientation 20 90 119

Orient SS 119 119

Organ SS 129 129

Organization 30 97 129 Recall SS

Reason SS

135 135

114 114

Recall 50 99 135 Sum SS = 367 = 249 = 616

Reason 44 83 114 Percentile Rank 98 97 99

SS 130 129 135

SCATBI Severity Score: 17 Alertness and Orientation Ms. Spears' level of alertness and orientation were found to be WFL. Patient was consistently oriented to person and place, and time. Ms. Spears was able to state her full name, age, where she is from, where she currently lives, where she was for the evaluation, the part of the day, day of the week, and current season. The patient successfully stated what happened to her (MVA) and how long ago she was in the hospital. Ms. Spears presented with no orientation or alertness deficits throughout the evaluation. Attention Ms. Spears presents with mild deficits in attention with a breakdown at the level of selective attention, which is not indicative of her scores on the SCATBI. Attention is Ms. Spears' largest area of deficit and her distractibility frequently interfered with several areas of the cognitive assessment. Ms. Spears was able to independently sustain attention during moderately complex tasks for 1 hour in both a non-distracting and distracting environment. To assess Ms. Spears' level of selective attention, external distractors (i.e. loud ticking clock was placed on the wall and door was opened) were incorporated into an informal assessment. Ms. Spears presented with a mild deficit in selective attention. She was unable to finish reading a paragraph out loud in a moderately distracting environment. Ms. Spears benefitted from moderate verbal cues from the clinician 60% of the time. However, the removal of 1 of the 2 external distractors (i.e. shutting the door) increased her accuracy of selective attention to 90% of the time, indicating her strength in selectively attending to the stimulus in a mildly distracting environment. Ms. Spears also presented with a moderate deficit in alternating and divided attention. Her scores on the SCATBI were inconsistent with her performance during informal assessments in a distracting environment. To determine Ms. Spears' level of alternating attention, she was given a starting number (16) and was asked to alternate between adding and subtracting the number 2 when prompted by the clinician. Ms. Spears' alternating attention during the task was WFL in a nondistracting environment, however, she presented with a moderate deficit in a mildly distracting environment. Divided attention was informally assessed by seeing if the patient could count the number of times 'and' was in an oral paragraph while also assessing for comprehension following the reading. Ms. Spears demonstrated alternating attention to be WFL in a non-distracting environment. In a mildly distracting environment, however, she was able to count 70% of the words and was able to answer 65% of the questions correctly for comprehension. Deficits were characterized by Ms. Spear's inability to attend to two tasks at once and return to a task once

distracted unless minimum verbal cues were given to redirect her attention. Ms. Spears was able to use the compensatory strategy of asking the clinician to slow down or for a one minute break when she became overwhelmed. Memory Ms. Spears' memory was found to be WFL on the SCATBI. However, during informal assessments, Ms. Spears' working and delayed memory skills were negatively influenced by mild attention deficits, but her immediate memory was not impacted. To assess Ms. Spears' immediate memory, Ms. Spears was instructed to match all pictures presented to her on a card, one at a time, with the corresponding picture in a distracting visual field. Ms. Spears completed the task independently. To assess if immediate memory was negatively impacted by attention, Ms. Spears was given strings of 4 and 5 words to repeat without delay in a moderately distracting environment (i.e. MU Clinic waiting room). Ms. Spears exhibited no deficits in immediate memory. Ms. Spears demonstrated her working memory to be WFL in a non-distracting environment during an informal task. To assess her level of working memory in a distracting environment, she was given the same task (i.e. moderately complex addition problem) and presented with a mild deficit. Ms. Spears benefited from repetition and verbal redirection to the problem. To test delayed memory, Ms. Spears was given a string of 5 numbers to remember. After taking a one-minute break, Ms. Spears was able to independently repeat the 5 numbers with 100% accuracy. Ms. Spears was given a different set of numbers to test if selective and alternating attention impacted her ability to recall the numbers after a one-minute delay in a distracting environment. Ms. Spears presented with a mild to moderate deficit in delayed recall. Ms. Spears benefited from repetition and decreased time of delay (i.e. 30 seconds). Ms. Spears presented with intact long term memory, which was not negatively influenced by attention deficits. To assess the patient's semantic long term memory, she was asked to verbalize the multiplication tables for 6 and 9. To assess her episodic long term memory, Ms. Spears was asked to talk about the first time she sang in front of an audience. Both tasks were successfully completed in a non-distracting and moderately distracting environment; Ms. Spears does not present any challenges in this area. Overall, Ms. Spear's short term and long term memory function is WFL in a non-distracting environment. However, when external distractors are incorporated into a task, she demonstrates a mild memory deficit in working and delayed memory. Executive Function Ms. Spears' scores on the SCATBI indicated a mild to moderate deficit in executive functioning skills. Ms. Spears' skills in initiation and termination were found to be WFL during formal and informal assessments. However, Ms. Spears presented with a mild to moderate deficit in planning and sequencing, problem solving, and cognitive flexibility. To rule out attention deficits, Ms. Spears was given initiation and termination tasks in a moderately distracting environment (i.e. writing 4 different sentences with the word 'letter'). Her initiation skills were WFL, however, she presented with a mild deficit in terminations skills secondary to attention. Ms. Spears exhibited a mild deficit in planning and sequencing when given an informal task to explain the steps to plan her trip back to UC Berkley (i.e. buy a plane ticket, pack, go to the airport, etc). The assessment was given in a non-distracting environment to rule out attention deficits. Ms. Spears did not provide necessary details for the trip, but benefitted from moderate verbal cueing from the clinician and writing down the steps on paper. During the Multiprocess

Reasoning: Analysis subtest of the SCATBI, Ms. Spears' mild to moderate executive functioning deficits were exhibited by her inability to problem solve a moderately complex task. Ms. Spears benefited from referring to visual cues (i.e. stimulus book) 2-3 times, which increased her accuracy to 100%. However, as the complexity of the task increased, Ms. Spears' ability to problem solve and understand the instructions decreased. She was unable to problem solve through the tasks and did not benefit from visual cues; internal distractors (i.e. frustration) negatively impacted her ability to solve the tasks. Ms. Spears was given a 2-minute break and was able to re-do and complete the problem solving task with 50% accuracy. She benefitted from referring to the stimulus book and taking notes. To assess Ms. Spears' cognitive flexibility, she was prompted by the clinician to generate multiple solutions to her selective attention deficit (i.e. copying an unfamiliar paragraph in a moderately distracting environment). Ms. Spears was able to independently remove 50% of the external distractors (i.e. closed the door). When prompted by the clinician, however, Ms. Spears removed 100% of the distractors and focused her attention on the task and completed it with 100% accuracy. Overall, Ms. Spears presents with a mild to moderate deficit in executive functioning skills, which will interfere with her responsibilities as a student and level of independence. Attention difficulties created challenges during the assessment, however, with moderate verbal cues and assistance, Ms. Spears was able to complete the tasks in a timely manner. Awareness Ms. Spears presents with a mild deficit in self-awareness. She has an intellectual level of awareness and understands that she has difficulties in the above areas. Ms. Spears can recognize a problem when it is occurring, however, she presents with a breakdown at anticipatory awareness. Initial patient interview and informal assessments indicate that Ms. Spears has a moderate deficit when anticipating problems due to her cognitive deficits and often overestimates her abilities. Ms. Spears benefits from stand by assistance and cues to anticipate a problem before it occurs and is able to independently take action to avoid it.

Clinical Impressions Ms. Spears presents with mild cognitive impairments characterized by mild deficits in attention and self-awareness and mild to moderate deficits in executive functioning. Ms. Spears level of alertness and orientation is WFL; she is oriented to person, place, and time and exhibits no deficits in awareness. Ms. Spears presents with intact sustained attention, however, mild selective attention deficits and mild to moderate alternating and divided attention deficits make it challenging for her to filter out external distractors and focus on a task. These deficits will impact Ms. Spears' responsibilities as a student such as studying in noisy environments and taking notes in class. Ms. Spears benefits from moderate verbal cueing (i.e. verbally redirecting her to the stimulus) and reduction of external distractors. Ms. Spears' short term and long term memory abilities were diagnosed to be WFL. However, her short term memory was negatively impacted by mild attention deficits. Ms. Spears presents with mild to moderate executive functioning deficits. Initiation and termination abilities are WFL, however, her termination skills are negatively influenced by attention deficits. Ms. Spears exhibits a mild to moderate deficit in planning and sequencing, problem solving, and cognitive flexibility. Ms. Spears benefits from performing executive functioning tasks in non-distracting environments, with moderate verbal cueing, and minimum assistance as needed. Lastly, Ms. Spears presents with a mild deficit in awareness, with a breakdown at anticipatory awareness. She exhibited improvement given stand

by assistance and moderate verbal cueing. Based on the results, Ms. Spears' mild cognitive deficits will impact her performance in school and her ability to live independently. It is recommended that the patient is under minimal supervision and attends a local school as a parttime student. Prognosis: Prognosis for improvement of Ms. Spears' attention and executive functioning skills and use of compensatory strategies is good depending on the patient's willingness to actively participate and family support. Recommendations: Based on the results of the evaluation, it is recommended that Ms. Spears receive outpatient speech therapy 2-3 times per week for one-hour sessions to work on improving her attention and executive functioning skills. An evaluation by OT is also recommended to assess driving. Therapy will focus on the following goals: Long term goals (3 months) 1. Patient will selectively attend to non-familiar, moderately complex cognitive-linguistic tasks independently in a highly distracting environment for 15 minutes with 80% accuracy. 2. Patient will independently perform moderately complex alternating and divided attention tasks for 15 minutes in a mildly distracting environment with 80% accuracy. 3. Patient will independently perform moderately complex short term memory tasks in a moderately distracting environment with 90% accuracy. 4. Patient will independently perform moderately complex executive functioning tasks with 85% accuracy. 5. Patient will independently perform moderately complex anticipatory awareness tasks during moderately complex ADL tasks with 90% accuracy. Short Term Goals (1 month) 1. Patient will perform selective attention to familiar, moderately complex reading tasks in a moderately distracting environment given minimum verbal cues for 10 minutes with 85% accuracy. 2. Patient will perform alternating and divided attention tasks between two moderately complex personally relevant tasks in a mildly distracting environment for given minimum verbal cues for 15 minutes with 80% accuracy. 3. Patient will perform moderately complex working memory writing tasks in a mildly distracting environment given minimum verbal cues with 90% accuracy. 4. Patient will perform moderately complex delayed memory tasks in a mildly distracting given minimum verbal cues with 90% accuracy. 5. Patient will generate multiple solutions to a moderately complex problem give minimum verbal cues with 85% accuracy.

6. Patient will plan and sequence moderately complex tasks given minimum cues with 85% accuracy. 7. Patient will perform simple anticipatory awareness tasks through prediction, modification, and analysis of performance during simple ADLs given minimum cues with 90% accuracy. Goals and recommendations were reviewed with Ms. Spears and Ms. Streep. Both were in agreement with plan and recommendations. Ms. Streep voiced willingness to carryover recommendations at home. Ms. Spears expressed her willingness to participate in therapy and carryover of compensatory strategies at home.

_____________________________________________ Cassandra Guarneros, B.A.