Memory and Executive Functions Subserving Judgments of Learning: Cognitive Reorganization After Traumatic Brain Injury.

We investigated relationships between psychometric measures of memory, executive functions (EFs), and task-based measures of Judgments of Learning (JOLs) in individuals with and without Traumatic Brain Injury (TBI), to study functional reorganization after TBI. We hypothesized that, in controls, accuracy of immediate JOLs would be associated with short-term memory and EFs (but not long-term memory, LTM), while accuracy of delayed JOLs would be associated primarily with LTM. We hypothesized that those with good recovery from TBI would demonstrate functional reorganization of the relationships between memory, EFs, and JOLs. Eighteen individuals with TBI and 18 matched controls completed eight neuropsychological tests of memory and EFs. They studied word-pairs, made immediate and delayed JOLs, and took a cued-recall test for the studied word-pairs. Stepwise regression and Lasso analyses generated a predictive model of JOL accuracy for each group. Accuracy of immediate JOLs in controls was predicted by short-term memory, inhibition, switching, and cognitive fluency, while accuracy of delayed JOLs was predicted by verbal recall. In individuals with TBI, inhibition predicted immediate JOL accuracy and switching predicted delayed JOL accuracy. Cognitive reorganization in those with good long-term recovery from TBI may account for the ability to make JOLs with accuracy similar to controls.

Public perceptions of traumatic brain injury: predictors of knowledge and the effects of education.

AIM: Existing research suggests that the public demonstrates inadequate knowledge about traumatic brain injury (TBI), indicating a need for public education initiatives; however, limited research exists on the effectiveness of these initiatives. The purposes of this study were to (1) identify whether any demographic/personal variables (e.g. gender, age, experience with TBI) predicted TBI knowledge and (2) determine whether presenting an educational video to members of the general public would improve knowledge about TBI. METHODS: Participants included 392 adults recruited from a state fair. Participants were divided into two groups, one of which viewed a 6-min video about TBI, and one which viewed an unrelated video. Participants completed measures relating to their backgrounds and knowledge about TBI. RESULTS: Greater educational attainment and professional experience with TBI were predictive of better TBI knowledge (F(1, 336) = 13.76 and 6.92, respectively, p < 0.01); no other demographic or personal variables predicted knowledge. Participants who viewed the TBI video demonstrated significantly better knowledge than participants who did not (F(1, 336) = 52.41, p < 0.0001). CONCLUSION: These results indicate that public education can result in immediate gains in public knowledge about TBI. Further research should include randomized controlled trials to determine long-term effectiveness of public education campaigns.

Evidence-Based Practice for the Use of Internal Strategies as a Memory Compensation Technique After Brain Injury: A Systematic Review.

OBJECTIVE: To complete a systematic review of internal memory strategy use with people who have brain injury and provide practitioners with information that will impact their clinical work. METHODS: A systematic literature search to identify published intervention studies that evaluated an internal memory strategy or technique to improve memory function of individuals with brain injury. Relevant data from reviewed articles were coded using 4 clinical questions targeting participants, interventions, research methods, and outcomes. RESULTS: A comprehensive search identified 130 study citations and abstracts. Forty-six met inclusion/exclusion criteria and were systematically reviewed. Visual imagery was most frequently studied, in isolation or in combination with other internal strategies. Despite significant variability in research methods and outcomes across studies, the evidence provides impetus for use of internal memory strategies with individuals following brain injury. CONCLUSIONS: Individuals with traumatic brain injury may benefit from internal memory strategy use, and clinicians should consider internal memory strategy instruction as part of intervention plans. Further research needs to better delineate influences on intervention candidacy and outcomes.

Psychometric properties of the college survey for students with brain injury: individuals with and without traumatic brain injury.

PURPOSE: The psychometric properties of the college challenges sub-set from The College Survey for Students with Brain Injury (CSS-BI) were investigated with adults with and without traumatic brain injury (TBI). METHODS: Adults with and without TBI completed the CSS-BI. A sub-set of participants with TBI were interviewed, intentional and convergent validity were investigated, and the internal structure of the college challenges was analysed with exploratory factor analysis/principle component analysis. RESULTS: Respondents with TBI understood the items describing college challenges with evidence of intentional validity. More individuals with TBI than controls endorsed eight of the 13 college challenges. Those who reported more health issues endorsed more college challenges, demonstrating preliminary convergent validity. Cronbach's alphas of >0.85 demonstrated acceptable internal reliability. Factor analysis revealed a four-factor model for those with TBI: studying and learning (Factor 1), time management and organization (Factor 2), social (Factor 3) and nervousness/anxiety (Factor 4). This model explained 72% and 69% of the variance for those with and without TBI, respectively. CONCLUSION: The college challenges sub-set from the CSS-BI identifies challenges that individuals with TBI face when going to college. Some challenges were related to two factors in the model, demonstrating the inter-connections of these experiences.

Masking release, processing speed and listening effort in adults with traumatic brain injury.

PURPOSE: This preliminary study explored differences between adults with and without traumatic brain injury (TBI) for speech processing accuracy, processing speed and effort in various conditions of interference. METHODS: Ten adults with TBI and six adults without TBI participated. Speech processing was studied using sentence repetition in six listening conditions with different types of interference, including noise and two simultaneous talkers. Participants repeated sentences and rated effort. Participants also completed standardized tests of cognition, including working memory and processing speed measures. RESULTS: Sentence repetition accuracy did not differ between groups. However, the TBI group demonstrated slower processing speed than the control group and also reported significantly greater effort in the two-talker condition. Faster processing speed was also correlated with higher accuracy in the two-talker condition. CONCLUSIONS: RESULTS of this study show group similarities in repetition accuracy across listening conditions, but group differences in speed and effort. This preliminary finding, as well as the relationship between processing speed and repetition accuracy, suggests that it is only in the most complex listening conditions that the effects of brain injury may be detectable.

Clock Drawing Test Performance of Young Adults Based on a One-Shot Case Study.

OBJECTIVE: The clock drawing test (CDT) is being used regularly by medical professionals in a variety of settings to aid in assessing cognitive functioning in adults of all ages. As our technological environment has changed significantly, because of the inception of this measure, the use of and exposure to the analog clock have diminished. We investigated whether young adults, who have grown up in a mainly digital world, can draw and tell time on an analog clock. METHOD: Participants aged 18-30 years (N = 80, Mage = 24.2, SD = 3.93), who self-identified as having normal cognition, completed the CDT, as well as setting hands on a pre-drawn clock and identifying analog clock times. RESULTS: About 25% of participants received a CDT score below the expected range. There was a moderate, positive correlation between analog clock hand setting and time identification in the group who scored below the expected range on the CDT only (rs(16) = 0.472, p = .048). Most participants reported not wearing an analog watch. CONCLUSIONS: Based on these findings, the CDT should be used with caution to screen cognitive functioning in young adults (i.e., aged 18-30 years). Consideration of an alternative approach to screening cognition and modifying cognitive assessments in which the CDT is embedded is recommended for this population. These findings warrant further investigation into CDT performance in the young adult population.

Self-regulated learning in a dynamic coaching model for supporting college students with traumatic brain injury: two case reports.

OBJECTIVE: To describe a program that integrates self-regulated learning theory with supported education for college students with traumatic brain injury using a dynamic coaching model; to demonstrate the feasibility of developing and implementing such a program; and to identify individualized outcomes. DESIGN: Case study comparisons. SETTING: University setting. PARTICIPANTS: Two severely injured students with cognitive impairments. INTERVENTIONS: A dynamic coaching model of supported education which incorporated self-regulated learning was provided for students with traumatic brain injury while attending college. OUTCOMES: Outcomes were both short and long term including decontextualized standardized test scores, self-reported academic challenges, number and specificity of reported strategies, grades on assignments, number of credits completed versus attempted, and changes in academic status and campus life. RESULTS: Students improved on graded assignments after strategy instruction and reported using more strategies by the end of the year. Students completed most of the credits they attempted, were in good academic standing, and made positive academic decisions. Performance on decontextualized tests pre- and postintervention was variable. CONCLUSIONS: It is feasible to deliver a hybrid supported education program that is dynamically responsive to individual students' needs and learning styles. Reasons for including both functional and standardized test outcomes are discussed.

Executive functions, self-awareness and quality of life in chronic moderate-to-severe TBI.

BACKGROUND: Moderate-to-severe traumatic brain injury (TBI) leads to significant neuropsychological impairment, further affecting quality of life (QOL). OBJECTIVE: Investigate the effects of chronic moderate-to-severe TBI on Executive Functions (EF), Self-awareness (SA), QOL, and the associations between them. METHODS: 33 males with moderate-to-severe TBI (ages 18-51; time since injury 1-19 years) were compared to 24 non-injured males, matched on age and education. EF measures included the Rey Complex Figure Test (copy), the Trail Making Test A & B, the Symbol Digits Modalities Test, and the Control Oral Word Association Test. SA was assessed using the Dysexecutive Questionnaire Revised, and the Self-Regulation Skills Interview. QOL and health-realted QOL were assessed using the WHOQOL-BREF and the QOL after Brain Injury, respectively. RESULTS: TBI participants scored lower on EF, and SA, reported less satisfaction regarding physical health and greater satisfaction with environmental support, than controls. TBI survivors scoring lower on EF, exhibited lower SA. Lower SA correlated with greater satisfaction regarding cognitive skills, self-perception, and overall HRQOL. Lower EF performance correlated with greater satisfaction in social relationships. CONCLUSIONS: The long-term effects of TBI on EF, SA and QOL seem to support the role of EF and SA on QOL, and therefore, the need for personalized interventions in improving recovery outcome.

White matter and neurocognitive changes in adults with chronic traumatic brain injury.

Diffusion tensor imaging was used to investigate white matter (WM) integrity in adults with traumatic brain injury (TBI) and healthy adults as controls. Adults with TBI had sustained severe vehicular injuries on the average of 7 years earlier. A multivariate analysis of covariance with verbal IQ as the covariate revealed that adults with TBI had lower fractional anisotropy and higher mean diffusivity than controls, specifically in the three regions of interest (ROIs), the centrum semiovale (CS), the superior frontal (SPF), and the inferior frontal (INF). Adults with TBI averaged in the normal range in motor speed and two of three executive functions and were below average in delayed verbal recall and inhibition, whereas controls were above average. Time since injury, but not age, was associated with WM changes in the SPF ROI, whereas age, but not time since injury, was associated with WM changes in the INF ROI, suggesting that the effects of WM on time since injury may interact with age. To understand the utility of WM changes in chronic recovery, larger sample sizes are needed to investigate associations between cognition and WM integrity of severely injured individuals who have substantial cognitive impairment compared to severely injured individuals with little cognitive impairment. (JINS, 2009, 15, 130-136.).

Metamemory adjustments over time in adults with and without traumatic brain injury.

PRIMARY OBJECTIVE: This study explored whether adults with and without traumatic brain injury (TBI) adjust their judgements of learning (JOLs) over the course of a verbal learning task. RESEARCH DESIGN: Regression analyses were performed of JOLs and recall over time, for both group means and individual performance. PROCEDURES: Twenty adults with TBI and 16 healthy controls studied lists of noun-pairs, making Likert scale JOLs for each item during the study phase. Half of the JOLs were made immediately following item study; the other half after several minutes delay. Recall was tested for each list after all JOLs were complete. OUTCOMES: Analyses revealed significant differences between participants with TBI and controls in how JOLs changed over time. As a group, TBI survivors increased JOLs over the course of the learning experiment in the delayed condition, whereas the control group decreased JOL predictions in the immediate condition. CONCLUSIONS: These results support previous work showing that metamemory abilities of adults with TBI are heterogeneous, but show some differences from those of healthy adults. Possible explanations are derived from Koriat's findings that, with practice, individuals tend to shift toward basing metamemory predictions on mnemonic cues rather than cues intrinsic to task items.

An electronic survey about college experiences after traumatic brain injury.

For many with traumatic brain injury (TBI), going to college is a realistic goal; however there is little documentation of the challenges faced by those with TBI who attend college. The primary purposes of this study were to document the academic challenges (studying, in-class experiences, time management, psychosocial aspects) reported by adults with TBI, and to investigate relationships between these challenges and the physical, cognitive and psychosocial consequences of TBI. An electronic anonymous survey was distributed. Of the 35 respondents with TBI, nearly all reported the need to review material more and a majority reported that others do not understand their problems. In-class experiences of being nervous before tests, forgetting what is said in class, and getting overwhelmed in class were also reported by a majority. Those who reported more physical, cognitive and psychosocial consequences of their injury also identified more academic challenges as well, although cognitive consequences alone predicted academic challenges better than all of the consequences combined. Psychosocial aspects also predicted academic challenges to a lesser extent. In spite of these findings, nearly half of the respondents had not heard of or had never accessed campus disability services. To develop effective on-campus service delivery models, additional research is needed to understand why students do or do not make use of existing services.

Predicting Remembering: Judgments of Prospective Memory After Traumatic Brain Injury.

Purpose: Adults with traumatic brain injuries (TBIs) often struggle with prospective memory (PM), the ability to remember to complete tasks in the future, such as taking medicines on a schedule. Metamemory judgments (or how well we think we will do at remembering) are linked to strategy use and are critical for managing demands of daily living. The current project used an Internet-based virtual reality tool to assess metamemory judgments of PM following TBI. Method: Eighteen adults with moderate to severe TBI and 20 healthy controls (HCs) played Tying the String, a virtual reality game with PM items embedded across the course of a virtual work week. Participants studied PM items and made two judgments of learning about the likelihood of recognizing the CUE, that is, when the task should be done, and of recalling the TASK, that is, what needed to be done. Results: Participants with TBI adjusted their metamemory expectations downward, but not enough to account for poorer recall performance. Absolute difference scores of metamemory accuracy showed that healthy adults were underconfident across PM components, whereas adults with TBI were markedly overconfident about their ability to recall TASKs. Conclusions: Adults with TBI appear to have a general knowledge that PM tasks will be difficult but are poor monitors of actual levels of success. Because metamemory monitoring is linked to strategy use, future work should examine using this link to direct PM intervention approaches.

Self-regulation strategies used by students with brain injury while transitioning to college.

PURPOSE: Students with TBI enter college with strategies that they have used prior to being injured yet often without knowing which ones will be effective in helping them to be successful. The purpose here is to describe how semi-structured interviews were used to identify self-regulated learning strategies, to demonstrate the utility and reliability of coding self-regulated learning strategies, and to provide examples of student-centered goals derived from survey and interview responses. METHODS: College students completed the College Survey for Students with Brain Injury (CSS-BI) and were interviewed before and after coaching support that focused on teaching self-regulated learning. Responses to interview questions about strategies were coded using a modified version of Zimmerman and Martinez-Pons's (1986) schema. Coders also rated strategies for specificity. RESULTS: Strategies were reliably coded into 16 categories of self-regulation. Inter and intra-reliability were strong. Four of the five students reported using a larger variety of self-regulation strategies and strategies that were more specific after coaching support. DISCUSSION AND CONCLUSIONS: It is possible to reliably code self-regulation learning strategies reported by college students with TBI. These measures have potential as functional 'outcomes' for students who are transitioning to college. Interview responses can be used to collaboratively create student-centered goals.

Delayed predictive accuracy of narrative recall after traumatic brain injury: salience and explicitness.

Fifteen adults with traumatic brain injury (TBI) and 15 adults without brain injury listened to narratives, made delayed predictions of recall, and took a delayed recall test. Narrative questions differed by salience (main ideas, details) and explicitness (implied, stated) (R. H. Brookshire & L. E. Nicholas, 1993). TBI survivors recalled less than control participants regardless of question type. All participants recalled main ideas and implied information with greater accuracy than details and stated information. Predictive accuracy for recalling stated information was strong regardless of group. Participants were unable to predict recall for implied information. The materials-appropriate-processing (MAP) hypothesis proposes that predictive accuracy is biased by text type (i.e., predictive accuracy for recalling main ideas should be higher than for details when learning narratives). However, there were no differences in predictive accuracy for recalling main ideas and details, with both groups predicting recall modestly well. Controlling for explicitness appears to be an important variable for future metamemory text studies.

Self-monitoring recall during two tasks after traumatic brain injury: a preliminary study.

Impaired recall is a common consequence of traumatic brain injury (TBI). Predicting recall during learning is a critical part of self-monitoring. Adults with TBI and noninjured controls made recall predictions of noun pairs that varied in prediction timing (immediate, delayed), and predictions of narrative information that varied in salience (main idea and details) and explicitness (stated and implied). For both groups, delayed recall predictions for noun pairs and stated (narrative) information were relatively accurate, whereas immediate recall predictions of noun pairs and delayed predictions of implied information were relatively inaccurate. Both groups were more confident making predictions of stated information than implied information. Neither predictive accuracy nor confidence generalized across tasks. Working memory load across tasks and individual differences are proposed explanations. The lack of generalization highlights the need to train domain or task-specific self-monitoring.

Breadth and depth of diversity in Minnesota: challenges to clinical competency.

This study explored the impact of recent demographic changes on clinical service delivery in the state of Minnesota. A Web-based survey was used to ask speech-language pathologists in Minnesota about their training, clinical caseloads, and professional experiences with respect to diversity. Primary survey goals were to (a) determine if, and how, recent changes in the overall state demographics were reflected on caseloads of speech-language pathologists, and (b) identify challenges clinicians faced in meeting the needs of an increasingly diverse population. The authors considered the breadth or range of economically, racially, ethnically, and linguistically diverse populations represented on caseloads, relative to depth of diversity. Survey results are discussed with respect to challenges inherent in providing services to a diverse caseload, together with the competencies needed in order to meet these professional challenges.

Implicit memory influences on metamemory during verbal learning after traumatic brain injury.

PURPOSE: Prior research has shown that individuals with traumatic brain injury (TBI) may be overconfident in their judgments of learning (JOLs; online measures of self-monitoring of learning and memory). JOLs had been presumed to be driven by explicit processes, but recent research has also revealed implicit memory involvement. Given that implicit learning mechanisms are often intact in those with TBI, the purpose of this study was to investigate whether priming and antipriming of immediate and delayed JOLs in individuals with TBI might affect their overconfidence. METHOD: A standard 3-field masked priming paradigm was combined with a paired-associate learning task with JOLs and administered to individuals with TBI and matched controls (18 per group). In each trial, a subliminal masked stimulus was immediately followed by supraliminal presentation of a word pair for study; participants also made immediate and delayed JOLs, with cued-recall testing 10 min after study and judgment. RESULTS: Antipriming significantly lowered JOLs and overconfidence for both groups, whereas delaying JOLs significantly improved recall for both groups. CONCLUSIONS: The results suggest that JOLs may be influenced by subliminal implicit memory. Clinical implications include the possible use of antipriming to reduce overconfidence after brain injury and delaying JOLs to improve recall.

Intervention for executive functions after traumatic brain injury: a systematic review, meta-analysis and clinical recommendations.

A systematic review of studies that focused on the executive functions of problem solving, planning, organising and multitasking by adults with traumatic brain injury (TBI) was performed through 2004. Qualitative and quantitative methods were used to evaluate the 15 studies that met inclusion criteria. Demographic variables, design and intervention features, and impairment and activity/participation outcomes (ICF) (World Health Organization, 2001) were documented. Five randomised control treatment (RCT) studies used step-by-step, metacognitive strategy instruction (MSI) and outcomes were evaluated in a meta-analysis. Effect sizes (ESs) from immediate impairment outcomes after MSI and "control" intervention were similar to each other, and both were significantly larger than chance. ESs from immediate activity/participation outcomes after MSI were significantly larger than the ESs from control intervention, and both were significantly larger than chance. These results, along with positive outcomes from the other group, single-subject design and single case studies, provided sufficient evidence to make the clinical recommendation that MSI should be used with young to middle-aged adults with TBI, when improvement in everyday, functional problems is the goal (Level A) (American Academy of Neurology, 2004). Although maintenance effects were generally positive, there was insufficient data quantitatively to evaluate this. Furthermore, there was insufficient evidence to make clinical recommendations for children or older adults. Intervention that trained verbal reasoning and multi-tasking was promising, although the evidence is insufficient to make clinical recommendations at this time. Additional research needs were highlighted.

Group intervention studies in the cognitive rehabilitation of individuals with traumatic brain injury: challenges faced by researchers.

There are many factors to consider in designing and interpreting group studies. These include both analytic considerations, such as the selection of valid and reliable outcome measures, and subjective considerations, such as the selection of outcomes that are perceived to be important to participants and researchers. In this paper, we review key issues to consider in the design of group studies in neurorehabilitation, using problem-solving studies in traumatic brain injury as an example.