Metacognitive accuracy predicts self-reported quality of life following traumatic brain injury.

OBJECTIVE: Metacognition and quality of life (QoL) are both adversely affected by traumatic brain injury (TBI), but the relation between them is not fully understood. As such, the purpose of this study was to determine the degree to which metacognitive accuracy predicts QoL in individuals with TBI. METHODS: Eighteen participants with moderate-to-severe TBI completed a stimulus-response task requiring the discrimination of emotions depicted in pictures of faces and then provided a retrospective confidence judgment after each response. Metacognitive accuracy was calculated using participants' response accuracy and confidence judgment accuracy. Participants also completed the Quality of Life After Brain Injury (QOLIBRI) questionnaire to assess QoL in various areas of functioning. RESULTS: Performance of a linear regression analysis revealed that higher metacognitive accuracy significantly predicted lower overall QoL. Additionally, higher metacognitive accuracy significantly predicted lower QoL related to cognition and physical limitations. CONCLUSION: The study results provide evidence of an inverse relation between metacognitive performance and QoL following TBI. Metacognitive changes associated with TBI and their relation to QoL have several clinical implications for TBI rehabilitation.

Post-acute rehabilitation effects on functional outcome and discharge disposition of people with severe traumatic brain injury.

Objective: This study's purpose was to document the effect of post-acute rehabilitation on functional independence of adults with moderate or severe traumatic brain injury (TBI). Methods: Retrospective analysis of admission and discharge scores on the Northwick Park Dependency Score (NPDS) and Mayo-Portland Adaptability Inventory - Fourth Edition (MPAI-4) as well as discharge disposition was performed for 271 adults admitted to post-acute rehabilitation between 2012 and 2017. Results: Discharge disposition was home for 83.39% of cases. Home discharge cases admitted to rehabilitation significantly sooner after injury than supported living discharge cases. Also, home discharge cases achieved significantly better NPDS and MPAI-4 scores both at admission and discharge than supported discharge cases. Analyses split by program duration revealed cases with ≤90 day stays were closer to injury upon admission and had significantly better admission and discharge NPDS and MPAI-4 scores than those with longer stays. Although NPDS and MPAI-4 change scores for home versus supported living discharge did not differ significantly, change scores for home discharge cases with ≤90-day programs were significantly smaller than those with >90-day programs. Conclusion: Findings support the notion that providing intensive post-acute rehabilitation may increase the functional independence of people with moderate or severe TBI.

Use of Visual Cues by Adults With Traumatic Brain Injuries to Interpret Explicit and Inferential Information.

OBJECTIVE: Concomitant visual and cognitive impairments following traumatic brain injuries (TBIs) may be problematic when the visual modality serves as a primary source for receiving information. Further difficulties comprehending visual information may occur when interpretation requires processing inferential rather than explicit content. The purpose of this study was to compare the accuracy with which people with and without severe TBI interpreted information in contextually rich drawings. PARTICIPANTS: Fifteen adults with and 15 adults without severe TBI. DESIGN: Repeated-measures between-groups design. MAIN MEASURES: Participants were asked to match images to sentences that either conveyed explicit (ie, main action or background) or inferential (ie, physical or mental inference) information. The researchers compared accuracy between participant groups and among stimulus conditions. RESULTS: Participants with TBI demonstrated significantly poorer accuracy than participants without TBI extracting information from images. In addition, participants with TBI demonstrated significantly higher response accuracy when interpreting explicit rather than inferential information; however, no significant difference emerged between sentences referencing main action versus background information or sentences providing physical versus mental inference information for this participant group. CONCLUSIONS: Difficulties gaining information from visual environmental cues may arise for people with TBI given their difficulties interpreting inferential content presented through the visual modality.

The diverse vocational experiences of five individuals returning to work after severe brain injury: A qualitative inquiry.

OBJECTIVE: The researchers explored the return-to-work experiences of five adults with severe traumatic brain injuries (TBIs) and those associated with them by performing a qualitative, multiple case study investigation involving in-depth, semi-structured interviews. Selection of this qualitative methodology allowed for personal, individualized accounts of adults with TBI returning to work. Specifically, this methodology promoted accurate representation of the idiosyncratic nature of each participant's experiences. METHODS: The researchers asked individuals to participate based on the diversity of their vocational experiences following TBI. RESULTS: Four of the five participants had returned to their pre-injury jobs. Two were subsequently fired and, at the time of research participation, were unemployed. One participant never returned to paid employment; however, he had held two volunteer positions for several years post-injury. Salient content from interview transcripts allowed for the identification of five to eight themes pertinent to each case. CONCLUSIONS: Interpretation of the themes led to three main conjectures about return-to-work experiences following TBI: (a) job satisfaction may relate more to involvement in productive activities than monetary compensation; (b) adults with TBI can be successful in holding and maintaining positions with high cognitive demands; and

Text-to-speech accommodations for the reading challenges of adults with traumatic brain injury.

OBJECTIVE: This study's purpose was two-fold: (a) to confirm differences in silent reading rates of individuals with and without traumatic brain injury (TBI) and (b) to determine the effect of text-to-speech (TTS) on reading comprehension and efficiency by individuals with TBI. DESIGN AND METHODS: Ten adults with severe TBI answered comprehension questions about written passages presented in three conditions: reading only (RO), listening to TTS presentation only (LO) or reading and listening to TTS simultaneously (RL). The researchers compared reading rate, comprehension accuracy and comprehension rate (efficiency) across conditions. RESULTS: Analysis revealed significantly slower silent reading rates for the participants with TBI than for readers without TBI (n = 75). Also, participants with TBI achieved higher comprehension accuracy for factual than inferential questions; however, no significant main effect for comprehension accuracy emerged across reading conditions. In contrast, using comprehension rate as the dependent measure, analysis confirmed a significant main effect for reading condition and question type; post-hoc pairwise comparisons revealed that the RL condition yielded higher comprehension rate scores than the RO condition. CONCLUSIONS: As a group, adults with TBI appear to benefit in reading efficiency when simultaneously listening to and reading written passages; however, differences exist that reinforce the importance of individualizing treatment.

Noun representation in AAC grid displays: visual attention patterns of people with traumatic brain injury.

Clinicians supporting the communication of people with traumatic brain injury (TBI) must determine an efficient message representation method for augmentative and alternative communication (AAC) systems. Due to the frequency with which visual deficits occur following brain injury, some adults with TBI may have difficulty locating items on AAC displays. The purpose of this study was to identify aspects of graphic supports that increase efficiency of target-specific visual searches. Nine adults with severe TBI and nine individuals without neurological conditions located targets on static grids displaying one of three message representation methods. Data collected through eye tracking technology revealed significantly more efficient target location for icon-only grids than for text-only or icon-plus-text grids for both participant groups; no significant differences emerged between participant groups.

Using Visual Scene Displays as Communication Support Options for People with Chronic, Severe Aphasia: A Summary of AAC Research and Future Research Directions.

Research about the effectiveness of communicative supports and advances in photographic technology has prompted changes in the way speech-language pathologists design and implement interventions for people with aphasia. The purpose of this paper is to describe the use of photographic images as a basis for developing communication supports for people with chronic aphasia secondary to sudden-onset events due to cerebrovascular accidents (strokes). Topics include the evolution of AAC-based supports as they relate to people with aphasia, the development and key features of visual scene displays (VSDs), and future directions concerning the incorporation of photographs into communication supports for people with chronic and severe aphasia.

Variations in Eye-Gaze Behaviors Evident When Five Adults With Aphasia-Based Alexia Read Multisentence Passages.

PURPOSE: The problems that people with aphasia encounter when reading passages are poorly understood. This study's purpose was in-depth examination of eye-gaze behaviors exhibited by five people with aphasia-based alexia. METHOD: Five adults with aphasia-based alexia and five neurotypical adults (NAs) read paragraphs while having their eye movements recorded. Acquired data included descriptive characterization of overall eye-gaze behaviors and determination of the (a) percent of fixated words, (b) average fixation duration, (c) average initial and total summed fixation durations of processing attempts on individual words, and (d) effects of word length and frequency on fixation durations. Careful examination of these data allowed examination of consistencies and discrepancies among people with aphasia and supported speculation about underlying deficits. RESULTS: Case participants exhibited unique fixation behaviors in comparison to one another and to neurotypical adults. Case participants' total reading time, percent of fixated words, average fixation duration, and average initial and total summed fixation durations on passage words exceeded those of neurotypical adults. Four of five exhibited positive word length and negative word frequency correlations with fixation durations. CONCLUSIONS: People with aphasia display eye-gaze behaviors unique to them and differing from those of NAs when reading texts. Better understanding of the connection between specific eye-gaze behaviors and problems decoding words, linking them with lexical-semantic information, and constructing meaning from written content is necessary to further progress in developing effective assessment tools and treatments.

Modality Synchronization When People With Aphasia Read With Text-to-Speech Support.

PURPOSE: Text-to-speech (TTS) technology potentially benefits people with aphasia by presenting content through two modalities simultaneously; however, for this to help, eye fixations must synchronize with the auditory rendition of words. Researchers have yet to explore how often and to what extent people with aphasia achieve modality synchronization. This retrospective analysis examined the percent of words people with aphasia see and hear concurrently when reading passages presented via TTS technology. Text-to-speech (TTS) technology potentially benefits people with aphasia by presenting content through two modalities simultaneously; however, for this to help, eye fixations must synchronize with the auditory rendition of words. Researchers have yet to explore how often and to what extent people with aphasia achieve modality synchronization. This retrospective analysis examined the percent of words people with aphasia see and hear concurrently when reading passages presented via TTS technology. METHOD: Nine adults with aphasia had their eye movements tracked while processing TTS passages at a preselected default rate of 150 words per minute. Modality synchronization occurred whenever fixation on a written word occurred during the time span beginning 300 ms before auditory presentation and ending at the next word's initiation. Correlations between standardized test scores, unsupported reading rate, and modality synchronization percentages were informative about the association of aphasia and reading impairment severity with achievement of synchronicity. RESULTS: Three participants demonstrated consistent modality synchronization; average synchronicity ranged from 67% to 76% of passage words. One participant displayed inconsistent synchronization within passages and achieved an average of 58%. The remaining five participants rarely achieved synchronization, with fixations typically lagging substantially behind the auditory presentation. A significant positive correlation occurred between paragraph reading comprehension test scores and modality synchronization percentages. CONCLUSIONS: A default TTS presentation rate does not result in dual modality synchronization for most people with aphasia. This lack of synchronization may contribute to inconsistencies in the benefit people with aphasia experience when provided with TTS support.

Environmental accommodations for a child with traumatic brain injury.

PRIMARY OBJECTIVE: Children with severe TBI frequently demonstrate language and cognition challenges and require accommodations to succeed academically. However, minimal research exists about accommodation efficacy for this population. This study examined the effect of environmental accommodations (reduced visual and auditory distractions) on the redirections, task variability and accuracy of a child with severe TBI when performing cognitive-linguistic activities. HYPOTHESIS: The researchers hypothesized no differences in variability between accommodation conditions; poorest task performance and most frequent task redirections given no environmental accommodations; comparable task performance and redirections with visual accommodation and auditory accommodation; and highest task performance and fewest redirections with combined visual and auditory accommodations. RESEARCH DESIGN: The researchers used an alternating treatment, single case design to compare task performance, variability and redirection averages across conditions. They used visual inspection, linear growth curve analyses and repeated measure analyses for data interpretation. METHODS AND PROCEDURES: Data collection occurred during label-object association, oral directions and divided attention tasks over 22 sessions varying in accommodation provision. MAIN OUTCOMES AND RESULTS: Findings showed visual plus auditory accommodations resulted in fewer redirections and superior average performance on all tasks although substantial variability persisted. Significant differences emerged across conditions only for the oral directions task.

Possible brain injury events and symptoms in elementary school children.

PRIMARY OBJECTIVE: The purpose of this study was to determine the prevalence of potential mild brain injury incidents accompanied by behavioural changes in a non-clinical population of elementary school-aged children. The researchers also examined data regarding the occurrence of possible brain injuries among regular vs special education students. RESEARCH DESIGN: Survey study. METHODS AND PROCEDURES: The researchers distributed questionnaires through which parents or guardians of 692 first-to-fifth grade students provided information about possible brain injury incidents and associated behavioural changes. MAIN OUTCOMES AND RESULTS: Findings suggest that as many as one-third of children experience one or more incidents potentially resulting in brain injury before completing elementary school. Despite this, only 7.66% of the sample received positive screen results because of behavioural changes associated with a potential incident. None of the 53 children with positive screens were receiving special education services through the traumatic brain injury category of IDEA at the time of the screening. Positive screens were more common among students verified for special education than those enrolled in regular education. Specifically, 25.40% of positive screen results were for children identified with a disability warranting special education services; in contrast, only 5.90% of regular education students received positive screen results.

Let the games begin: a preliminary study using attention process training-3 and Lumosity™ brain games to remediate attention deficits following traumatic brain injury.

PRIMARY OBJECTIVE: Computer-based treatments for attention problems have become increasingly popular and available. The researchers sought to determine whether improved performance by survivors of severe traumatic brain injury (TBI) on two computer-based treatments generalized to improvements on comparable, untrained tasks and ecologically-plausible attention tasks comprising a standardized assessment. RESEARCH DESIGN: The researchers used an -A-B-A-C-A treatment design repeated across four adult survivors of severe TBI. METHODS AND PROCEDURES: Participants engaged in 8 weeks of intervention using both Attention Process Training-3 (APT-3) and Lumosity™ (2010) Brain Games. Two participants received APT-3 treatment first, while the other two received Lumosity™ treatment first. All participants received both treatments throughout the course of two, 1-month intervention phases. MAIN OUTCOMES AND RESULTS: Individual growth curve analyses showed participants made significant improvements in progressing through both interventions. However, limited generalization occurred: one participant demonstrated significantly improved performance on one of five probe measures and one other participant showed improved performance on some sub-tests of the Test of Everyday Attention; no other significant generalization results emerged. These findings call into question the assumption that intervention using either APT-3 or Lumosity™ will prompt generalization beyond the actual tasks performed during treatment.

Text-to-speech technology effects on reading rate and comprehension by adults with traumatic brain injury.

OBJECTIVE: This study's purpose was to examine the comprehension, rate and perceptions and reading preferences of adults with severe traumatic brain injury (TBI) when reading passages with and without computerized text-to-speech (TTS) support. DESIGN AND METHODS: Nine adults with severe TBI read 24 passages in two conditions: with and without TTS support. The researchers compared reading rate and comprehension accuracy across conditions. Also, participants rated their perceived performance and reading preferences via a follow-up questionnaire. RESULTS: Comparison to normative data revealed that all nine participants read slower than average neurotypical readers. As a group, participants read significantly faster with TTS support than without such support, even though the TTS reading rate was roughly comparable to the oral rather than silent reading rate of neurotypical adults. No significant differences in comprehension resulted between the two conditions. Over half of the participants preferred the TTS condition over the no-TTS condition. In general, participants were inaccurate in judging their relative reading rates and comprehension accuracy across conditions. CONCLUSIONS: TTS may improve reading efficiency without compromising reading comprehension accuracy for adults with TBI. Given this finding, some survivors may find use of TTS technology contributes to increased participation in and efficiency when performing reading activities.

Speech and Language Characteristics of Neurologically Healthy Adults When Describing the Modern Cookie Theft Picture: Mixing the New With the Old.

PURPOSE: The Modern Cookie Theft picture has recently become available. This study's purpose was to compare (a) speech and language production by neurologically healthy adults (NHAs) given a generic instruction to describe the picture versus instruction to describe it as if talking with someone who was blind and (b) production during the first 90 s versus full samples. METHOD: One hundred NHAs minus five outliers formed two participant groups. Each group heard either the original or modified task instruction. Transcriptions of resulting descriptions were analyzed regarding duration, word and T-unit productivity, content units (CUs), and main concepts (MCs) both in full and 90-s samples. Identified CUs and MCs were compared with existing lists from previous research. RESULTS: Significantly longer samples and greater verbosity occurred with the modified versus original instruction even when limiting time to a 90 s maximum. With the modified instruction, CUs included 119 and 138 terms for truncated and full samples, respectively; participants mentioned 98 and 104 CUs, respectively, given the original instruction. MCs expressed were 18 and 19 for truncated and full samples, respectively, given the modified instruction; with the original instruction, this dropped to 11 and 12 MCs for truncated and full samples, respectively. Within samples, CU and MC repetitions were greater given modified rather than original instruction. CONCLUSIONS: Normative productivity and content generation data are critical for guiding diagnostic efforts and treatment planning. Benefits and detriments associated with differing productivity and content redundancy secondary to varying instructions and analysis time frames are discussed.

Eye Fixation Behaviors and Processing Time of People With Aphasia and Neurotypical Adults When Reading Narratives With and Without Text-to-Speech Support.

BACKGROUND: Researchers have used eye-tracking technology to investigate eye movements in neurotypical adults (NAs) when reading. The technology can provide comparable information about people with aphasia (PWA). Eye fixations occurring when PWA do and do not have access to text-to-speech (TTS) technology are of interest because the support improves reading comprehension and decreases processing time for at least some PWA. AIMS: This study's purpose was to examine forward, regressive, and off-track eye fixations when PWA and NAs read narratives in read-only (RO) and TTS conditions. A secondary aim was to examine the influence of eye fixations on processing time. METHOD AND PROCEDURE: A Tobii Dynavox Pro Spectrum eye tracker recorded eye movements of nine PWA and nine NAs while reading narratives in two conditions. Movements of interest were forward fixations; within-word, within-sentence, and previous-sentence regressive fixations; and off-track fixations. OUTCOMES AND RESULTS: PWA exhibited significantly more forward and regressive fixations in the RO than TTS condition, whereas NAs showed opposite behaviors. NAs had significantly more off-track fixations in the TTS than RO condition, whereas PWA exhibited no difference across conditions. PWA took significantly longer to process content in the RO condition, whereas NAs took longer in the TTS condition. CONCLUSIONS: PWA and NAs differ in important ways when processing texts with and without TTS support. Examining eye-tracking data provides a means of gaining insight into the decoding and reading comprehension challenges of PWA and helps elucidate how assistive technology can mediate these challenges.

A Mixed-Methods Exploration of the Experience of People With Aphasia Using Text-to-Speech Technology to Support Virtual Book Club Participation.

PURPOSE: This mixed-methods research sought to examine the experience of people with aphasia who used text-to-speech (TTS) support to read a novel for virtual book club participation. METHOD: Six people with chronic aphasia used a TTS system to review portions of a novel about which they conversed during eight virtual book club meetings occurring over 5 weeks. During one-on-one interactions prior to each meeting, participants answered comprehension questions and provided feedback about reading experiences. Then, during group meetings, they reviewed and discussed relevant book content and predicted upcoming content. During a structured individual interview, participants reflected on their supported reading and book club experience. RESULTS: Participants reported a range of reading confidence prior to study participation, mostly influenced by decreased comprehension or reading speed. After book club participation, four participants expressed increased confidence. Some reported searching for key words and skipping difficult words as strategies additional to TTS support. All reviewed at least some book sections more than once either with or without TTS support. Highly motivated participants expressed low frustration and high reading ease and enjoyment. Perceived comprehension was roughly consistent with actual comprehension across participants. Most believed TTS support promoted faster reading than otherwise possible. Participants liked adjustable features affecting speech output rate, word or sentence highlighting, and font size. Psychosocial benefits included decreased isolation and increased friendship. CONCLUSIONS: The findings extend previous evidence about perceived and actual benefits associated with TTS support. People with aphasia express positive experiences when given TTS support during book club participation.

Informal Written Language Analysis Methods: Case Examples of Adults With Traumatic Brain Injury.

PURPOSE: Written expression challenges following traumatic brain injury (TBI) in adults have received little clinical attention but can substantially affect quality of life and the success of reintegration efforts. Assessment tools and procedures are lacking despite the likelihood of post-TBI problems with microstructure (e.g., productivity, spelling accuracy) and macrostructure (e.g., topic adherence, organization) aspects of written language. The lack of standardized procedures forces reliance on informal methods to determine writing strengths and challenges. METHOD: A combination of assessment procedures allowed for evaluation of the productivity and efficiency, adherence to writing conventions (e.g., spelling, sentence structure, punctuation), and macrostructure organization (e.g., story grammar, topic adherence) of written narratives collected from five adults with TBI. RESULTS: Use of multiple assessment methods revealed disparate writing challenges across the five case examples. The differing writing profiles underscore the necessity of evaluating multiple aspects of written narratives. CONCLUSIONS: The described analysis methods can help clinicians determine areas of strength and challenge in written work generated by adults with TBI. Examination of multiple aspects of writing is key to garnering a comprehensive appraisal of post-TBI writing.

Perceptions About Writing by Adults With Moderate or Severe Traumatic Brain Injury.

PURPOSE: Writing challenges can cause ongoing distress and limit resumption of pre-injury activities following traumatic brain injury (TBI); however, little TBI research or clinical practice addresses written communication. Understanding the writing perceptions and experiences of adults engaged in intensive, inpatient rehabilitation following hospital discharge for TBI is an initial step in addressing this situation. METHOD: Transcendental phenomenology served to structure this qualitative research. Six adults between 2 and 6 months post-TBI participated in a common experience of writing about a personal memorable event. Standardized test scores and symptom ratings provided descriptive information about participants. Additionally, participants completed the Neurobehavioral Symptom Inventory and NASA Task Load Index and engaged in semistructured interviews to describe writing perceptions and experiences. RESULTS: Data analysis revealed themes and subthemes about writing perceptions, challenges, and support strategies. Participants varied in their perceptions of post-injury writing changes. Test results revealed areas of challenge for all participants, but only half reported awareness of writing changes. Those aware of changes differed from other participants regarding word retrieval, memory, and concentration as well as overall effort expended, frustration, and performance quality. Although all participants relied on writing supports, only one had adjusted multiple writing strategies following injury. CONCLUSIONS: Some adults with TBI are aware of writing changes while receiving posthospital, inpatient rehabilitation services, but others deny such changes. This differs from reports concerning later recovery stages, perhaps because few functional writing opportunities arise during rehabilitation. Application of compensatory strategies specific to post-injury writing challenges is unlikely while awareness remains limited.

Comprehension, Processing Time, and Modality Preferences When People With Aphasia and Neurotypical Healthy Adults Read Books: A Pilot Study.

BACKGROUND: Many people with aphasia (PWA) want to read books. Text-to-speech (TTS) technology sometimes provides comprehension and processing time benefits when PWA read short, multisentence passages. Currently, no research examines the effect of TTS support when PWA read books. AIMS: This study's primary purpose was to examine comprehension accuracy and total processing time of PWA and neurotypical healthy adults (NHAs) when reading book sections in read-only versus TTS-supported conditions. A secondary aim was to examine condition preference and perceived degree of understanding by people in both participant groups. METHOD AND PROCEDURE: Ten PWA and 10 NHAs alternated between read-only and TTS-supported conditions to read a book. Participants answered comprehension questions and provided feedback about their reading experience, condition preference, and desire to use TTS technology for future book reading. Outcomes and Result: Overall, PWA exhibited less accurate comprehension and slower processing times compared to NHAs in both conditions. No significant comprehension accuracy difference occurred between conditions for either group. However, four PWA exhibited a 10% or greater increase in comprehension accuracy when receiving TTS support. A significant processing time difference occurred with PWA processing text faster with TTS support, whereas NHAs did not demonstrate processing time differences. Most PWA preferred the TTS condition and expressed a desire to use TTS technology in the future. Most NHAs expressed the opposite preference. CONCLUSIONS: TTS support during book reading promotes faster processing without compromising comprehension for PWA. Clinicians should discuss with PWA the relative importance of comprehension accuracy, processing time, and comfort with technology when determining whether using TTS support during book reading is desirable.

Reading Comprehension and Processing Time When People With Aphasia Use Text-to-Speech Technology With Personalized Supports and Features.

BACKGROUND: Person-centered approaches promote consistent use of supportive technology and feelings of empowerment for people with disabilities. Feature personalization is an aspect of person-centered approaches that can affect the benefit people with aphasia (PWA) derive from using text-to-speech (TTS) technology as a reading support. AIMS: This study's primary purpose was to compare the comprehension and processing time of PWA when performing TTS-supported reading with preferred settings for voice, speech output rate, highlighting type, and highlighting color versus unsupported reading. A secondary aim was to examine initial support and feature preference selections, preference changes following TTS exposure, and anticipated functional reading activities for utilizing TTS technology. METHOD AND PROCEDURE: Twenty PWA read passages either via written text or text combined with TTS output using personally selected supports and features. Participants answered comprehension questions, reevaluated their preference selections, and provided feedback both about feature selections and possible future TTS technology uses. OUTCOMES AND RESULTS: Comprehension accuracy did not vary significantly between reading conditions; however, processing time was significantly less in the TTS-supported condition, thus suggesting TTS support promoted greater reading speed without compromising comprehension. Most participants preferred the TTS condition and several anticipated benefits when reading lengthy and difficult materials. Alterations to initial settings were relatively rare. CONCLUSIONS: Personalizing TTS systems is relevant to person-centered interventions. Reading with desired TTS system supports and features promotes improved reading efficiency by PWA compared with reading without TTS support. Attending to client preferences is important when customizing and implementing TTS technology as a reading support.