Final Exam Flashcards
1
Q
If the audiologist/SLP is not bilingual or multilinguial then use of non-English materials is considered _______ the scope of practice.
A
outside
2
Q
The least desirable option if audiologist or SLP. is not proficient in client’s language is to have a _____ _____ interpret.
A
family member
3
Q
Best practice would be for audiologist or SLP to be _____ in client’s language. Next best practice would be to use ______ _____ who is familiar with terminology and has the ability to convey meaning from one language to another.
A
proficient
trained interpreter
4
Q
American Sign Language is a ______ l language that is distinct from ______ _____.
A
manual
spoken English
5
Q
ASL has its own set of ___ and ______ structures.
A
rules
syntactical
6
Q
Over _____ signs are iconic and be interpreted intuitively.
A
6000
7
Q
______ ____ and _____ language are critical for communication in ASL
A
Facial expressions
body
8
Q
ASL is extensively used within and among the _____ community
A
Deaf
9
Q
What are the primary goals of American Sign Language?
A
- To be the deaf individual’s primary language which allows them to communicate prior to learning to speak or replace the use of oral speech.
- Prepares the child for social access to the Deaf community.
- Amplification is not a requirement for success with ASL.
- Child needs to have access to deaf/and or hearing adults who are fluent in ASL as well as being educated about Deaf culture.
.
10
Q
Any individual who has difficulty in speech perception needs _________.
A
speechreading
11
Q
Any individual who does not respond appropriately to speech even with the use of hearing aids or cochlear implant need ______.
A
speechreading
12
Q
Who needs speechreading?
A
- Any individual who has difficulty in speech perception.
- Any individual who does not respond appropriately to speech even with the use of hearing aids or cochlear implant.
13
Q
How can the speaker facilitate speech reading?
A
- Best if face-to-face or within a 45 degree angle of speechreader
- Normal rate of speech (up to 15 phonemes per second) or slightly slower is best
- Extremely slow and exaggerated speech does not assure comprehension
- Facial expressions and gestures are extremely helpful
14
Q
How can the speaker hinder speech reading?
A
- Poor articulating/mumbling
- Fast or slow speech (without good rhythm)
- Someone with an accent
- Speaker with a mustache
- Emphasis on particular words , unless there is a facial expression associated are difficult to grasp.
- Over-exaggeration of articulators does not help the speechreader.
- Vocabulary level should match the level of the speech reader.
15
Q
One of the multicultural aspects in audiology speech pathology is to develop cross ________ ________ to be an effective clinician.
A
cultural awareness
16
Q
Signed exact English is another form of ________ communication.
A
manual
17
Q
The primary goal of signed exact English is to allow an easier transition to _______ and ______ English.
A
reading
writing
18
Q
The word order of signed exact English _____ English _____ structure.
A
parallels
sentence
19
Q
What is the second most widely used form of manual communication?
A
Signed exact English
20
Q
What are the objectives necessary to develop cross cultural awareness to be an effective clinician? There are 4.
A
- Be aware of the diversity between cultures.
- Develop sensitivity awareness for cultures other than your own (including Deaf culture)
- Develop cultural specific awareness and understanding by reading and asking individuals who can serve as a “cultural guide”.
- Respect individuals from other cultures.
21
Q
What are the signal and code factors that affect speechreading?
A
- Visemes: Distinguishiable visual characteristics of phonemes (th, f)
- homophenes - Phonemes that appear the same
- homopheneous words - words that appear the same (pet, bed).
- In conversational speech, most phonemes occur in the medial position and are less identifiable that they are in isolation.
- Visibility -Many phonemes are not visible. Voicing is also a feature that is not visible.
- Speed - due to the rapidity of connected speech, many articulatory movements occur for a short period of time.
- Redundancy allows the speechreader to fill in the parts of the message that were missed.
- Short sentences are easier to read than longer sentences.
- Frequently used words are easier to read than less frequently used words.
22
Q
What are three environment factors that affect speechreading?
A
- Distance: 5 feet between speaker and speeechreading is optimal.
- Lighting: Should provide contrast between speaker’s face and background. Lighting source should not be behind speaker.
- Angle: 0-45 degree angle is best
23
Q
What are the visual factors that affect speechreading? (6)
A
- The light should allow the speaker to be easily visible to speech reader.
- The distance should be sufficient to allow for the face, particularly the lips, to be clearly visibly.
- The obscurity of many speech sounds (homophoneous words ex. bill and pill) make speech reading difficult.
- The rapidity of the formation of speech sounds makes it difficult to read.
- Hidden sounds such as /j/ (as in you) or /h/ for which there is no movement are difficult to speech read.
- The speech reader should face the speaker in the beginning but should eventually practice speech reading from different angles.
24
Q
_________ strategies structure the environment and situation to facilitate communication.
A
Facilitative
25
_______ strategies recover from communication breakdowns.
Repair
26
Facilitative strategies include:
________ visibility of the speaker (lighting, angle, distance)
_______ competing ________ (voices, environment).
Maximizing
Minimizing
noise
27
Name the five repair strategies.
1. repetition
2. rephrasing
3. simplification
4. elaboration
5. confirmation of what was said
28
________ speechreading training programs are available but ________ instruction is preferable.
Computerized
| face-to-face
29
Speech reading support groups address ______ ______. Speechreader listens for _____ ____ so he/she knows when the _______ is being changed.
preparatory set
topic cues
topic
30
Speechreading support groups work on ______ of the message. Speechreader requests a ___________ of the messag ewhen the speaker finishes. Speechreaders ____ what was to confirm/clarify the message.
redundancy
recap/summary
restates
31
What psychosocial aspects are affected by a hearing loss?
1. self concept
2. self esteem
3. public perception
32
The _________ development is affected by a hearing loss.
emotional
33
Due to a hearing loss the _________ development of an individual is affected. _________ delays affect their understanding of ________. They miss a lot of ______ learning. Many appear ______ for their age as a result.
```
emotional
language
emotion
incidental
immature
```
34
Psychological responses to hearing loss may have parents moving in and out of hte following stages of the grief cycle:
- Shock, disbelief, denial
- Depression
- Anger and guilt
- Acceptance
35
____________: self defense mechanism which is used to protect oneself from crisis. Threat, fear of what the future holds; future is unknown.
Shock, disbelief, denial
36
________: mourn a sense of loss such as loss of hearing and loss of effortless conversation; worry about what may lay ahead.
Depression
37
_________: why me? what did I do to deserve this? Unfair, too young. Parents may feel they have caused their child's hearing loss; see it as a reflection of themselves- weak, disability.
Anger, guilt
38
________: Final stage, person realized that life goes on, although different than before.
Acceptance
39
Family members, particularly ________, take the brunt of the burden for filling in the gaps for the hard of hearing person.
spouses
40
Families perceive the HI individual as ______ or ______ which leads to them being labeled as ______, _____, ______.
```
unsociable
paranoid
senile
confused
hostile
```
41
At home, HI individuals may believe that those closest to them don't understand ______ of hearing loss which may lead to ______, ______ and ______ toward the spouse or children.
ramifications
anger
frustration
resentment
42
The hearing impairment often leads to ______ withdrawal and often results in ______.
social
| depression
43
_______ _______ are blamed for not speaking clearly, mumbling or leaving them out of the conversation.
Family members
44
The HI individual does not realize the _____ he/she is placing on the spouse/family.
burden
45
The ________ person usually reports a greater benefit after the hearing aid fitting that the _____ individual
non-impaired
| HI
46
What is the minimal hearing loss?
16-25 dB
47
People with _______ hearing loss (16-25 dB) are often unaware of ______ conversational cues which causes the HI individual to be viewed as _______ or _______.
minimal
subtle
awkward
inappropriate
48
People with ________ hearing loss may exhibit _______ behavior.
minimal
| immature
49
People with ______ hearing loss may miss portions of fast paced _____ ______ which impacts _______ and ____ _____.
minimal
peer interaction
socialization
self concept
50
________ impact on hearing loss is greater as the hearing loss ______.
Psychosocial
| increases
51
What is the range of mild hearing loss?
26- 40 dB
52
Child/adult with a _____ hearing loss has a negative impact on _______ as the they are accused of hearing ____ they ______ to ______, ________, and not ______ _______.
```
mild
self-esteem
what they want to hear
daydreaming
paying attention
```
53
Child/adult with a _______ hearing loss has difficulty hearing and understanding speech in ____ ______, making the _______ _______ stressful.
mild
background noise
learning environment
54
Child is more ________ than classmates due to greater listening effort that's needed.
fatigued
55
What is the range of the moderate hearing loss?
41 - 55 dB
56
_______ is significantly affected with a _______ hearing loss.
Communication
| moderate
57
_______ of people with ______ hearing loss with normal hearing peers becomes increasingly _______.
Socialization
moderate
difficult
58
Full-time use of hearing aids and or FM system causes people with a _______ hearing loss to be viewed as a less ______ _______, impacting _______.
moderate
competent learner
self-esteem
59
What is the rnage for people with a severe to profound hearing loss?
71 - 90 dB
60
People with a ________ to ____ hearing loss have the same effects as ______ hearing loss but to a greater degree and they begin to prefer socializing with ______ _____ ____ or _____ individuals
severe to profound
moderate
hearing-impaired
Deaf
61
Severe to profound: Individuals with late onset deafness find it difficult to maintain ties with the _____ world but they have no pre-established ties to the _____ community. They do not know _____.
hearing
Deaf
ASL
62
Counseling process: Establish a _____ with your patient in order to :
help the patient _____ their hearing loss
help the patient/family members develop _____ to alleviate the problems associated with their hearing loss.
partnership
accept
solutions
63
A speech pathologist should not enter into the realm of the clinical _____ or ______ when counseling patients.
psychologist
| psychiatrist
64
When personal adjustment issues become emotional, the client should talk ___ and the counselor should talk ____.
more
| less
65
Counseling should be ______ counseling.
informational
66
Counseling should be center on the course of action best suited for the _______.
individual
67
Counseling should be _____ by the individual and/or family.
guided
68
Counseling process should be supportive of the individual and ____ _____.
family members
69
Personal adjustment counseling can also use _____ ______ questionnaires that target ______ ____ and their ______ to their hearing loss.
self-assessment
specific situations
reactions
70
Personal adjustment counseling includes an ______ in which the client tells you about their ______ ______.
interview
| hearing loss
71
The personal adjustment counseling interview includes the following (5):
1. what situations they have difficulty hearing in
2. How hearing loss has affected them
3. what their goals are
4. what their ambitions are
5. what their coping strategies or defense mechanisms are
72
Audiological rehabilitation begins long before the child reaches _______ age.
school
73
Prior to the universal newborn hearing screening, the average age of identification of hearing loss was ____ months. Parents usually tend to suspect hearing loss for ____ months before the child is diagnosed.
18-30
| 12
74
Only about ____ of newborns who fail the hearing screening actually make it to the pediatric audiologist and early intervention specialists.
50%
75
Babies who are screened at 1 month can be fitted with hearing aids by ____ months and be in early intervention programs by 6 months of age.
3
76
The FDA recommends cochlear implanting no earlier than ____ months of age. However, physicians can decide to implant ______. _____ size and _____ ____ are used to determine age of implantation.
12
earlier
head
body weight
77
In Germany, they routinely implant bilaterally at age ____ months of age.
6-7
78
Programs often fail the families, but the blame may be placed on the ______ failing.
implant
79
If the child is treated early in a good program, they can be on level by ____ or ______.
kinder
| 1st grade
80
We need more programs to brain SLPs to specialize in auditory learning and spoken language such as ______ and ______ ______ _____.
listening and spoken language specialists
81
Training programs tend to be geared toward _____ _____ classes. But, ___ of students with hearing loss are capable of being served in ________ _______ classes.
self-contained
90%
general ed
mainstream
82
Auditory -verbal program is usually provided in _______ _____.
private practice
83
Auditory verbal program is most effective with students whose amplified hearing is within the _____ to _______ _____ range.
average
| moderately severe
84
Auditory verbal program must be provided by a certified ______ ____ ______.
auditory verbal therapist
85
Auditory verbal program teaches listening skills through one on one therapy focusing on the use of the child's ______ hearing with the use of _______.
residual
| amplification
86
Auditory verbal training stresses auditory _______, auditory _______, _________ development, ________ development and _______.
```
awareness
processing
language
speech
cognition
```
87
Auditory verbal program emphasizes maximizing the _______ potential of the child.
auditory
88
Auditory verbal program requires intensive investment of _____ and ______ on the part of the patient who is expected to incorporate on-going training into child's ______ and _____ activities.
time
money
routine
play
89
Ideally in the Auditory verbal program the ______ is present in every session learning how to work with the child to improve spoken communicative interactions.
parent
90
Auditory verbal program does not allow the use of any form of _______ communication.
manual
91
Auditory verbal program is most effective is child is _____ and ____ begins at an early age.
amplified
| treatment
92
Auditory verbal program allows hearing impaired children to grow up in regular ______ and ________ environments that enable them to become independent and contributing citizens of mainstream society
living
| learning
93
Auditory verbal program is proven to be one of the most successful programs in developing ______ and _____ skills in hearing impaired children.
auditory
| verbal
94
Auditory Oral Program is provided in ______ and ______ schools.
public
| private
95
Auditory Oral Program: Parents are encouraged to carryover training activities to assist developing ______, _____ and ______ skills.
listening
speechreading
speech
96
Auditory Oral Program is most effective with students whose amplified hearing is within ______ to ______ range.
average to moderately severe
97
Auditory Oral Program is most effective if child is ______ and _______ begins at an early age.
amplified
| treatment
98
Auditory Oral Program focuses on the development of _____ language, primarily through the use of aided ______, including _______ training.
oral
audition
speechreading
99
Auditory Oral Program does not use ____ for communication but may allow _____, ____ speech or ________ _______ for clarification of speechreading, articulation and or reading skills.
ASL
gestures
cued
visual phonics
100
Auditory Oral Program: Child learns to communicate with _______ speech.
intelligible
101
Auditory Oral Program: Child attends his neigborhood school with ______ students.
hearing
102
Auditory Oral Program: May require additional services of an ______ or ____ teacher.
itinerant
| AI
103
Total communication Program is provided in a ______ ____ _____ program for the _____ because they require the services of an _____ in classrooms in which the teachers do ___ _____.
Regional day school program for the Deaf
interpreter
not sign
104
Total communication Program: Philosophy is to develop _____ modes of communication including (9):
several
1. listening
2. oral language
3. sign language
4. fingerspelling
5. speechreading
6. contextual cues
7. facial expressions
8. natural gestures
9. body language
105
Total communication Program: teacher and students _____ and _____ simultaneously.
voice
| sign
106
Total communication Program is often taught prior to introducing a child to an ______ program to develop a means of communication. These children tend to develop ______ language sooner than children in strictly oral programs.
oral
| receptive
107
Total communication Program: Family members should learn _______ and continue learning as the child's vocabulary and communication broadens so should that of the family members.
sign language
108
Total communication Program: All subjects are taught in the _________ _________ ________ necessary to meet the student's needs.
least restrictive environment
109
In the least restrictive environment the _____ teacher goes into general ed. classroom to work with AI students.
AI
110
_______ ______ is the primary mode of communication in School for the Deaf.
Sign language
111
School for the Deaf in Austin is a ______ school for Austin residents.
day
112
School for the Deaf is _____ for students who live outside of Austin but in Texas.
residential
113
School for the Deaf is from ____ to _____ _____.
kinder
| high school
114
______ ______ indicates that some type of hearing loss is present
hearing impairment
115
_______ _________Indicates mild to severe loss in one or both ears..
hard of hearing
116
______ Indicates severe to profound bilateral hearing loss
deaf
117
_____ Denotes cultural identification
Deaf
118
IEP
Individualized Educational Plan
119
ARD
Admission, Review, Dismissal meeting in which the IEP is developed (term only used in Texas)
120
_____ _____ _____Location/setting in which special education services are provided with or without general education students present.
Least restrictive environment
121
_______ audiologist manage and maintain amplification equipment.
Educational
122
Educational audiologist fit ____ ______ and transmitters.
FM receivers
123
______ _____ conduct audiologic evaluations on hearing impaired individuals as deemed necessary.
Educational audiologist
124
Educational audiologist participate in ______ (attend when necessary)
ARD
125
Evaluation and treatment of speech and language disorders in children with hearing impairment:
1. auditory training
2. language therapy
3. speech therapy
4. speech reading instruction
126
Speech language pathologist can check and troubleshoot ______ _____ and report any problems to the educational audiologist.
amplification systems
127
Speech language pathologist provide support and suggestions to enhance ______ training, _______ development, _______ skills and carryover of speech skills to AI teacher and classroom teacher.
auditory
language
speechreading
128
Speech language pathologist provide suggestions for reducing ______ in the classroom.
noise
129
ASHA's gudielines for audiometric screening allow ____ with ____ and a license to conduct hearing screenings in school. However, TX requires it be done by ____ _____.
SLPs
CCC
school nurses
130
_______ teacher provide additional support with an interpreter if needed.
Resouces
131
_____ teacher provide academic instruction and support in the general ed classsroom.
AI
132
_______ teacher provide academic pull-out support ot students who receive their primary instruction in the ______ classroom.
AI
| general ed.
133
_____ teacher provide academic instruction in the AI classroom.
AI
134
________ _______ specialize in teaching skills in areas that AI students typiclaly have difficulty (language)
AI itinerant teacher
135
______ ______ _______ help AI students to _______ for themselves when their special needs are not being accommodated
AI itinerant teacher
| advocate
136
______ _______ assess verbal and nonverbal intellectural abilities.
school psychologist
137
School psychologist administer ____ test and administer formal ______ _____.
IQ
| academic assessments
138
Students whose primary mode of communication is sign language are entitled to the use of an _____ in all subject areas that are taught by a teachers who is not using sign.
interpreter
139
Students can request an interpreter at ______ if they feel the need.
recess
140
At ARD meetings or any other legal conference with deaf parents, a certified level ____ or ____ interpreter must be present
3 or 4
141
When a deaf student is being given formal evaluations such as IQ testing speech and language assessments a certified level __ or ___ interpreter must be present.
3 or 4
142
For all other education or extra-curricular purposes a level ___ or ___ interpreter may be utilized.
1 or 2
143
_____ _______ ______ ____ refers to difficulty listening to or comprehending auditory information through the central nervous system despite having normal hearing sensitivity.
Central Auditory Processing Disorder
144
What is the European terminology for Central processing Disorder?
Auditory processing disorder
145
CAPD involved ______ ___ and ____ ___ processing.
bottom up and top-down
146
______ _____ processing involves information carried from the ear to the brain and falls within the realm of the audiologist.
Bottom-up
147
____ ____ processing refers to how information is acted upon once it gets to the brain. Affects how information is organized retrieved and categorized. Typically falls within the realm of the speech language pathologist.
Top-bottom
148
Despite the difference in perspective, audiologist and SLPS need to think about CAPD from an ________ perspective
interdisciplinary
149
CAPD is manifested by poor performance in one or more of the phenomenon as listed in the scale of auditory behvaiors:
1. difficulty hearing or understanding in background noise
2. misunderstands, especially with rapid of muffled speech
3. difficulty following oral directions
4. difficulty discriminating and identifying speech sounds.
5. inconsistent responses to auditory information.
6. poor listening skills
7. asks for things to be repeated
8. easily distracted
9. learning or academic difficulties
10. short attention span
11. daydreams, inattentive
12. disorganized
150
Overall managements of central auditory processing disorders should be _______ based on the child's specific profile.
individualized
151
For young children, under age of 7 who exhibit characeristics of CAPD, focus on ____ skill development as you would with a young _____ _____ child.
auditory
| hearing-impaired
152
Central auditory processing disorder: plan management based on the concerns listed on questionnaires from the ______ and ______.
parent
| teacher
153
_____ ___ intervention strategies include:
Bottom-up
phonological processing training
auditory training
154
_____ ______ intervention strategies include:
top-bottom
listening to audio books
prosody training
language based training
155
Management of central auditory processing disorders: _____ training requires coordination across the brain providing benefits in _____ processing.
music
| auditory
156
APD in the elderly: _______ the decline in hearing due to varous types of auditory system dysfunction.
Prebyscusis
157
Prebyscusis refers to ______ as well as central auditory processing disorder.
peripheral
158
An adult with prebyscusis will have more difficulty listening with ____.
noise
159
Auditory processing disorders are not predictable from an _______.
audiogram
160
_______ regression affects _______ recognition.
Phonemic
| word
161
APD: The _______ perception may become confused or distorted.
phoneme
162
APD; _____ alone may not correct phonemic regression.
Amplification
163
CAPD may coexits with:
```
bipolar disorder
schizophrenia
Alzheimer
stroke
epilepsy with temporal lobe involvement
aging
```
164
Audiologist must have information from ________ in order to diagnose the disorder. (CAPD)
multi-disciplines
165
The elderly who have a central auditory processing disorder do have a _____ _____ as opposed to children who do not.
hearing loss
166
Children with or without hearing loss, do not have the ____ ___ of an adult.
listening skills
167
The higher cortical areas of the brain are not fully developed until around the age of ____.
25
168
An enriching _____ environment encourages auditory brain development.
acoustically
169
_____ alone does not teach a child to listen any more than normal hearing guarantees the development of _____ ____.
Amplification
| listening skills
170
A purposeful attempt must be made to teach the child what to ____ for. The child must be able to put ____ to what he hears.
listen
| meaning
171
______ skills are used as a means of learning.
Listening
172
____ to _____ ratio is the relationship between auditory signal (speech) and background noise; anything in the environment that ______ with the perception of the auditory signal
speech to noise
| interferes
173
Enhanced speech to noise ratio _____ intelligibility and focuses on ______ input.
maximizes
| auditory
174
Optimal distance is ____ inches from ear or microphone of assistive listening device.
6
175
Speech characteristics of individuals with postlingual deafness: hearing assists us in _______ and _____ our speech skills.
monitoring and maintaining
176
Speech characteristics of individuals with postlingual deafness: The acquisition of a ____ to _____ hearing loss rarely requires speech therapy.
mild to moderate
177
Speech characteristics of individuals with postlingual deafness: Once an adult loses ____ input, he loses his auditory ______ system.
auditory
| monitoring
178
Speech characteristics of individuals with postlingual deafness: A hearing loss causes a gradual deterioration of speech skills if the individual is not ______.
amplified
179
Speech characteristics of individuals with postlingual deafness: Hearing impairment may affect ______ of speech, speech production, reduced _____ quality due to inability to monitor _____ of voice as well as _____, _____, and ______.
```
intelligibility
voice
loudness
stress
intonation
pitch
```
180
Speech characteristics of individuals with postlingual deafness: If amplified soon after acquiring a significant hearing loss most will be able to maintain their ____ skills.
speech
181
Causes of hearing loss in adults:
- exposure to hazardous levels of recreational or occupational noise over extended periods of time
- aging process (prebyscusis) in which there is a gradual deterioration of hearing over time.
- illness
- trauma
- medications
182
ASSESMENT CORE: ____ _____ what are the impairment and activity limitations regarding communication?
Communication Status
183
Communication status: What are the impairment and activity limitations regarding communication?
- limitations of impairment can be determined by the audiogram
- activity limitations can be determined by the self-report such as a case history that provides information about day to day limitations in communication.
184
Overall participation variables include:
self assessment scale
types of self assessment scaled
audiologist
185
Overall participation self assessment scale deals with:
- situations in which they are having diffculties hearing
- limitations in communication activity
- psychosocial effects their feelings about the hearing loss.
186
Overall Participation: types of self assessment inlcude:
- heairng handicap inventory for the elderly
- Denver scale of communication function for senior citizens living in retirement centers
- the communication profile for the hearing impaired.
187
overall participation: audiologist may give:
- APHAB abbreviated profile of hearing aid benefit
- COSI client oriented scale of improvement(patient can tell audiologist in what situation they want to hear better. Looks at benefit and satisfaction
188
The APHAB and COSI can be used as an _____ measures to determine if hearing aids are _______ or if other forms of treatment are successful.
outcome
| effective
189
ASSESSMENT: related perosnal factors incldue:
- attitudes and motivation for treatment
- activity level
- health status
- manual dexterity
- vision
- memory
190
ASSESSment: environmental factors included:
- community: hearing loss association of america
- Availability of assistive listening devices
- support systems-family support find out how much support the patient is getting from family and friends in their environment.
191
Management CARE
counseling
audibility-amplification
remediation for communication activities
environmental and participation improvement
192
________ begin by listening to the patient talk about their hearing loss. Using the information found during your assessment work with the patient to formulate ____.
Counseling
| goals
193
________ involves fitting the hearing aid, CI or ALDs and orientation to amplification device
Audibility-Amplification
194
______ for communcation activities nehances communication between ________ partners.
Remediation
| communication
195
Remediation for communication activities involves instructing hte patient on how to :
```
control the listening environment
be assertive in getting needs met
set realistic expectations
speech read
use of anticipatory and repair strategies
```
196
________ and participation involvement ensures that the goals for rehabilitation are ______ in every day life.
Environmental
| achieved
197
Environmental and participation improvement: The goals should clearly state ____ will do what and how much by______
who
| when
