Post Assessment of the Effects of Memory Retraining on Adolescents and Young Adults with TBI/ABI

Post Assessment of the Effects of Memory Retraining on Adolescents and Young Adults with TBI/ABI
Mary Margaret Hines
Integrative Project for Master’s Degree: PSY5201
Capella University
March 16, 2011

Table of Contents
Abstract 6
Introduction 7
Relationship to career 8
Purpose of the project 11
Potential contributions 11
Literature Review 12
Definitions of memory 12
Short term memory 12
Long term memory 13
Retrospective memory 13
Prospective memory 13
Semantic memory 13
Episodic memory 14
Visual memory 14
Relation of Brain Structure to Memory 14
Characteristics of Adolescents and Young Adults with TBI 16
Memory deficits 17
Executive functioning 18
Verbal discourse 18
Visual memory 19
Approaches 19
Internally focused interventions 20

Externally focused interventions 24
Intervention 30
Project purpose 32
Elements of the intervention 33
Eligibility 33
Target population 33
Target behaviors 34
Baseline data 34
Text message intervention 35
Potential contributions 35
Identifying change 35
Implications for students 36
Implementation 36
Design 36
Structure 37
Consent 38
Determination of targets 38
Diary assessment 39
Introduction of the mobile phone 39
Return to baseline 40
Reflections/Conclusions 40
Practitioner-Researcher Attributes/Goals 41
Professional attributes 41
Theoretical orientation 41
Culturally skilled practitioner 42
Ethical dilemmas 42
Diverse/Multicultural views 43
Action plan 45
Strengths 45
Ethical principles 45
Developing competence 46
Respect for individual differences 46
Limitations 46
Application of theory 46
Communicate effectively 46
Goals to build on strengths 46
Psychological standards 46
Peer reviewed articles 47
Goals to build on limitations 47
Differing theories 47
Report quantitative findings 47
Strategies to reach goals 47
Synthesis of Coursework 48
Career Expectations and Plans 48
Contributions of educational measurement specialists 48
Application of education measurement specialists 48
References 49

Post Assessment of the Effects of Memory Retraining on Adolescents and Young Adults with TBI/ABI
Abstract
The focus of this project is to investigate the effects of a specific memory retraining strategy for adolescents and young adults with TBI/ABI. Participants chosen for the intervention include youth who have sustained a traumatic brain injury and are between the ages of 13 to 23. Usability and potential of mobile phone technology will be evaluated as a compensatory aid for these individuals. Findings of the study may positively influence educator and rehabilitation staff perceptions regarding programming options for traumatic brain injured youth. An evidence based approach that utilizes psychological principles is the foundation for this project. Each element is built on the previous one to create a foundation that reflects scholarly and professional principles. The literature review will cite information from reputable sources such as professional journal and books. All parts of the intervention are described and will include what will be done to answer the research question, describe how it will be accomplished, and the rationale for why specific procedures were chosen. A description of the materials and how the results are to be analyzed are also included in this stage (Kallet, 2004). How effective the intervention has been or will be and how changes are determined for stakeholders are also included. All of the changes that affect different groups are identified here as well as how the findings will be presented.

Introduction

Traumatic brain injuries (TBI) are reported at epidemic rates with an annual incidence for children in the United States of an average of 1 million (Arryoyos-Jurado, Paulsen, Ehly & Max, 2006). The estimated incidence of TBI doubles between the ages of 5 and 14 years and peaks for both males and females during adolescence and early adulthood for approximately 250 per 100,000 incidents. Demographic studies have established that the frequency of head injury increases in the under-24 age group, with males ages 14-24 two times more likely to sustain a head injury than females.
Traumatic brain injuries occur when the head is struck or moves abruptly, resulting in a possible loss of consciousness. Causes of TBI include falls, a blow to the head, or the head striking a stationary object (Czubaj, 1996). Medical professionals, according to Masel & Dewitt (2010), frequently categorize brain injuries as mild, moderate, or severe based on the length of time an individual is unconscious and the severity of the tissue damage to the brain. Mild traumatic brain injury is, in most cases, a concussion and there is full neurological recovery, although many of these patients have short-term memory and concentration difficulties (Bay, Kreulen, Shavers, & Currier, 2006). In moderate traumatic brain injury the patient may be lethargic, and, in severe injury, the patient is comatose and unable to open his or her eyes or follow commands. These persons may display confusion, dysphagia, dysphasia, and problems with motor coordination as well as complications with memory (Bay, Kreulen, Shavers, & Currier, 2006). These medical categories however, do not necessarily reflect the severity of future impact on that person’s life. Most significant brain injuries are accompanied by various changes in behavior. These may include irritability, anxiety, and depression, as well as, the capacity for planning and organization, problem solving skills, mental flexibility, abstract reasoning, initiation, motivation and regulation of behavior (Bay, Kreulen, Shavers, & Currier, 2006). Much of the behavior change is directly related to the brain region and the system affected.
Symptoms that are associated with brain injuries include brief alteration in orientation, headaches, dizziness, reduction in attention, concentration and memory. Lingering memory problems prevent many survivors of brain injury from returning to active employment, independent living, and leading full social lives long after most physical disabilities have reached stabilization or recovery (Schonberger, Ponsford, Reutens, Beare, & O’Sullivan, 2009). Horneman and Emanuelson (2009) indicated from research that children with moderate and severe TBI who displayed persistent neuropsychological deficits during the first year post injury showed improvements over the first year but had a slower rate of improvement over a three year span. Age at injury is considered to be an important factor that contributes to memory and intellectual outcome. The children who are injured earlier are reported to have the poorest outcomes (Horneman & Emanuelson, 2009).
Relationship to Career
According to Stiles, Reilly, Paul & Moses, (2005), a traumatic brain injury can affect the speed, duration, and interpretation of input. Language, academic achievement, emotions and behavior are also included in the affected areas, along with cognitive skills that involve reasoning, problem solving, mental learning and organization.
Advances in knowledge of memory function have been beneficial to treatment approaches for memory deficits as a result of traumatic brain injuries. Neuropsychology is the study of how the functions of the brain and the nervous system affect thinking and behavior.
Neuropsychological examinations assess several functional domains (Kushner, 1998). These domains include processing of information that involves combining a multitude of sensory information with existing knowledge; cognitive skills (reasoning and problem solving, mental flexibility, memory and learning); language; (fluency and comprehension, verbal skills); academic achievement; emotions; motor performance; orientations and attention; and behavior (social skills). A neurological assessment according to Kushner (1998) usually includes a history of the client’s problems, including a review of past and current medical conditions; individual descriptions of the client’s intellectual, cognitive, sensory, and psychomotor skills; emotional and behavioral status; and family support systems and their value to the client. The information contained in the neurological report is intended to facilitate and enhance rehabilitation treatment planning and goal setting.
Second, neuropsychology has examined memory and the impact of TBI on memory deficits (Rohling, Beverly, Faust & Demakis, 2009).
Third, rehabilitation specialists have used the data to facilitate daily functioning, such as remembering grocery lists and scheduled appointments, engaging in appropriate social interactions (i.e. remembering names and social engagements, and employment related skills such as arriving to work on time and maintaining deadlines) (Rohling, Beverly, Faust & Demakis, 2009). This form of rehabilitation known as cognitive rehabilitation involves directly retraining cognitive processes that have been injured. It may also involve the use of compensatory strategies to enhance performance on everyday tasks. Cognitive rehabilitation focuses on individuals with deficits in brain functioning that are caused either by traumatic brain injuries or developmental disabilities.
As a clinician, identifying the trauma as the primary factor of the problem may not be sufficient in all cases for implementing an intervention. There may be other problems as identified by Masel & DeWitt (2010),
Cognitive neuropsychologists seek the same answers to questions about cognitive functioning as cognitive psychologists, but formulate their studies differently. They focus on individuals with “deficits” in brain functioning. These are deficits caused by either brain injuries or developmental disabilities. One goal of the assessment is to determine how the traumatic injury has affected the individual’s psychological functioning and to examine other possible domains of impairment. This will enable the clinician to develop an intervention plan using new assessment information. Clinical interviews and trauma-specific self-report instruments should be used to collect data (Pereira, 2007).
Cognitive behavior treatments can typically be delivered in either a group or an individual format. Treatment plans involve providing information to the individual regarding the trauma and their treatment options. Education therapies often involve teaching the survivor how the different areas of the brain affect mood, memory and behaviors. The trauma survivor is taught how to monitor and record information about his or her own thoughts and behaviors (Pereira, 2007).
Two main approaches are associated with cognitive-behavioral therapy. The first approach involves assisting the individual with replacing irrational beliefs through the use of psychotherapy, hypnotherapy, and desensitization. The second approach, involves helping the survivor identify how their thoughts and behaviors are related and to design interventions that are specific to the resulting deficits (Cobb, Sample, Alwell, & Johns, 2006).

Purpose of the project. The purpose of this project is to review a sample of cognitive-behavioral interventions for adolescents and young adults after being treated for a TBI/ABI. The article focuses exclusively on adolescents and young adults having experienced a traumatic brain injury but does not discuss symptoms associated with other learning disabilities (Dykeman, 2001). The interventions described in this article have the potential to generalize to other disabilities as they may demonstrate some of the same characteristics of a traumatic brain injured individual with regards to memory impairment.
This study will provided insight to the effects of TBI/ABI to the processing centers. The unique contributions of the study are to help increase awareness of the influence of the cognitive-processes on memory, and the development of treatment methods with a distinctive cognitive focus. The concentration is on a detailed analysis of higher cognitive functions such as memory and attention. The interest is in brain pathology and the resulting symptoms and a psychological interest in the analysis of the cognitive functions to develop rehabilitation techniques (Ylvisaker, Jacobs, & Feeney, 2003). Because the child and adolescent’s brain is so vastly different from the adult brain different treatment methods that have been developed or restructured for the young adult are also of interest.
Potential contributions. This study was designed to assess memory retraining strategies on adolescents and young adults after brain injury. Numerous studies have shown according to Schonberger, Ponsford, Beare & O’Sullivan (2009) that TBI/ABI has lasting impacts on an individual’s cognitive, behavioral, and physical well-being. This may result in long-term effects on various areas of the person’s life including independent living, occupation, relationships, and social and emotional adjustment. However, there is variability in the outcomes of the findings and predicting of outcomes. Severity of injury and complexity of the TBI/ABI related result make investigation of the effectiveness of rehabilitation strategies for student survivors of TBI/ABI difficult. Findings will be used to highlight gaps in the scientific evidence that supports cognitive rehabilitation indicating future research in the area with a focus on technology. Implications for educators and educational programming for working with adolescents and young adults following a TBI/ABI will be discussed (Arryos-Jurado, Paulsen, Ehly, & Max, 2006). Recognizing the strengths and challenges of the student with a TBI/ABI to help them reach a level of independence is paramount in the education field (Hux, Bush, Zickefoose, Holmberg, Henderson, & Simanek, 2010). Strategies that are recommended for use include memory notebooks, visual diagrams, drill and practice, listening to material (rather than reading it) and the use of technology such as computer assisted programs.

Literature Review

Memory
Features of memory impairment include definitions of the various types of memory. Patients and families, along with researchers have made observations that distinguish between types of memory access and retrieval (Schooler, Caplan, Revell, Salazar, & Grafman, 2008).

Definitions
Short term memory. The two types of memory referred to in literature are immediate memory or short-term memory, and long term memory. Short-term is the memory for recent events. This type of memory is demonstrated in events that just happened such as reading a phone number from a piece of paper and remembering it long enough to dial. Information, such as this, is kept in short-term memory for a few seconds unless it is repeated or intentionally memorized. Working memory refers to short-term memory when it is used to perform a task, such as, recalling the directions for completion of assignments (Dykeman, 2001).
Long-term memory. Long-term memory refers to the recall of a large-capacity, long-term store of information that was presented at least 30 minutes prior to recall such as procedures and rules (Pereira, 2007). Long-term memory is demonstrated by remembering vocabulary learned as a child, having a conversation, remembering names of people, following safety rules, and procedures for preparing meals. Long-term memory is considered to be the most crucial for acquisition and retention of new information as well as for access to all previously learned information. Long-term memory is also the domain of language and other linguistic information, and therefore, is the most critical for communication (Pereira, 2007).
Retrospective memory. Short-term and long-term memory functions are also referred to as retrospective memory or the ability to remember past events or previously presented information. Some examples include remembering routines, directions, names, lists, and personal identifiable information such as addresses and phone numbers (Pereira, 2007).
Prospective memory. There are many activities that require ability to remember to perform tasks in the future (D’ydewalle, Bouckaert & Brunfaut, 2001; & Pereira, 2007). This is referred to as prospective memory tasks. Examples may include remembering to bring money to school for lunch or to bring a signed permission slip back.
Participants in TBI rehabilitation programs are often required to engage in prospective memory tasks such as arriving on time for classes, remembering to complete assignments, and self-administering medication appropriately. These memory issues can interfere with functional restoration throughout the rehabilitation program. They can also be the limiting factor for independent living and social integration (Kim, Burke, Dowds, & George., 1999).
Semantic memory. Semantic memory is defined as memory for verbally represented information and represents facts, concepts, organization of knowledge of the environment and also aids in the appreciation and interpretation of experiences (Schmitter-Edgecombe, & Anderson, 2007). These structures are viewed as necessary for understanding the relationships among to-be-remembered events and for processing and organizing these events so that they can be remembered.
Episodic memory. Episodic memory is described as memory for information related to aspects of personal happenings or events such as remembering the sequence of a job task, information for a test, or the events of a day. Both semantic memory and episodic memory may be observed in short-term and long-term memory functions (Schmitter-Edgecombe, & Anderson, 2007).
Visual memory. The ability to remember visual patterns and spatial positions is essential in several occupations such as graphic design, driving, and piloting. It is also important for everyday activities such as remembering where an object has been placed or following directions in a new location. Difficulties in these activities can lead to frustration, embarrassment, or even risk (Newsome, et al. 2008).

Relation of Brain Structure to Memory
In the past, the concept of memory has been subdivided into smaller processes and a larger number of brain structures have been implicated (Schooler, Caplan, Revel, Salazar, & Grafman, 2008). Research indicates performance on semantic memory tasks to be associated with the left frontal lobe while visual episodic memory tasks are reflected with functioning from both the right temporal lobe and the right frontal lobe. Verbal episodic memory tasks are assumed to be linked with the left temporal lobe and the left frontal lobe. Short term memory tasks have been related to a variety of brain structures including the hippocampus, the cingulated, the temporal lobes, and the frontal cortex.
The hippocampus according to Giap, Jong, Ricker, Cullen, Ross, & Zafonte (2000), is important for the consolidation of new information. Damage to this area restricts learning of new skills and encoding. Memory loss is directly proportional to the amount of cell loss in the hippocampus during injury. Damage to the temporal lobes can restrict verbal recall, storage, and retrieval, and alternately, damage to the frontal lobes appears to impair memory for remembering which group of multiple events occurred first as well as impairment in the ability to replicate a temporal pattern of behaviors. These structures are responsible for the process in prospective memory tasks.
Even if the origin of the impairment is similar, the types of impairment may differ. This indicates a need for individual assessments of memory impairment types. Because memory can be negatively affected by many factors, the treatment of memory deficits may take many different forms. The most effective type of treatment, used in a specific case, is dictated by the type of memory impairment (Bajo, & Fleminger, 2002). To identify the most appropriate therapy or intervention the characteristics of the student or young adult that include severity, type of the problem, medical diagnosis, demographic variables, and social variables should be taken into account.
In the past, it has been assumed that nothing could be done for an individual with a brain injury to restore cognitive and/or behavioral functions including memory. The improvement that did occur was thought to be spontaneous recovery and the brain’s potential for recovery was limited due to cell death and the inability of cells to regenerate. While the brain injury itself cannot be reversed, current research involving brain structures and development shows promising effective treatment options to assist with the recovery of cognitive functioning and functional independence (Rohling, Beverly, Faust, & Demakis, 2009). These options include the development of, and compliance with, daily routines, greater reliance on external information storage systems (such as daily planners an calendars), the use of note taking and audio recording to record lengthy information exchanges (such as lectures and meetings), cell phones, I-pods, laptop computers, delineating tasks to specific components, and implementing environmental modifications to reduce distractions (Dykeman, 2001).

Characteristics of Adolescents and Young Adults with TBI
Adolescents and young adults who experience traumatic brain injuries demonstrate a wide variety of functional impairments. These neurological impairments may include general intellectual ability, verbal, perceptual, constructual, and executive functions, memory ability, orientation and attention, motor performance, personality, social and emotional functioning. Individuals with impairments, according to Arryoyos-Jurado, Paulsen, Ehly, & Max (2006), in these areas, may be able to complete individual jobs but may have great difficulty devising and following a sequence of job tasks to completion, especially if the task necessitates flexibility and creative problem solving. They may also have difficulty following social rules such as proximity control, working out problems with peers and coworkers, expressing needs, and moving from one location to another.
In the past, studies have suggested brain development is the product of ongoing and continually changing, biological and environmental outcomes. Brain injuries often affect large portions of the cerebral hemisphere that results in memory impairments or other cognitive disabilities (Stiles, Reilly, Paul, & Moses, 2005)
The course of recovery for the adolescent varies according to the site and extent of injury according to Dykeman (2001). The recovery typically involves three stages. Stage I recovery often includes displays of agitation, impulsivity and confusion. Youth in stage II recovery often show intolerance for stimulation, with a denial of cognitive disability and with increasing behavioral demands made upon the teachers and caregivers. The youth may exhibit behaviors that seem inappropriate and immature such as temper tantrums. Stage III recovery is demonstrated with an increasing understanding of the nature and type of cognitive deficits associated with the brain injury along with an understanding of the lasting nature of these deficits. As a result, youth in the third stage become susceptible to anxiety, frustration, and anger.

Memory Deficits
Deficits in memory can arise from difficulties with encoding, storage, or retrieval. Problems at each of these stages could be the result of slower rates of processing, decreased attention, and an inability to process information semantically (Arroyos-Jurado, Paulsen, Ehly, & Max, 2006).
In a review of the research, Arroyos-Jurado, Paulsen, Ehly, & Max (2006) concluded that children and adults with a traumatic brain injury, show persistent cognitive and behavioral deficits despite a resumption of normal daily routine. In addition, the severity of brain injury has strong correlation with the degree of deficits that can interfere with academic and social performance of students with TBI. In a study of twenty-seven children with TBI, academic, social and neuropsychological assessments were conducted to assess functions involved in learning and recalling verbal information, academic functioning, and severity of brain injury. A logistic regression analysis was conducted to determine if there was a significant relation between performance at 2 years following injury and participation at the 6 to 8 year follow up. Significant correlations were found between pre-morbid functioning and academic outcome, r=.49; p=.047 and r-.60; p=.01. Severity of injury was correlated significantly with the change score from immediate post-injury performance IQ to the 6 to 8 year performance IQ (r= -.54; p=.006). Findings from the study suggest that severity of injury is the best indicator of intellectual change 6 to 8 years following a TBI. The results showed that children and adolescents with more severe injuries tended to use a serial clustering strategy for remembering words and phrases than mildly or moderately injured peers.
Executive functioning. Adolescents with TBI experience significant executive functioning deficits when compared to youth with TBI. The executive functioning of 16 adolescents experiencing TBI from auto accidents were evaluated using the Profiles of Executive Functioning and The Recognition for Memory Test. Youth with TBI were classified into two severity groups: Borderline and Mild/Moderate/Severe (MMS) based upon the Scales of Cognitive Ability for Traumatic Brain Injury. Working memory between control (M-106.63,SD=2.20), borderline (M=103, SD=7.44), and MMS groups (M=75, SD=32.28). Furthermore, working memory was significantly correlated with executive functioning (r=.8). Similar findings were reported for working verbal memory and executive functioning. In both cases, the borderline group did not significantly differ from the control group. However, the MMS scored significantly lower than the control group. Scores on executive functioning were for control, M=45, SD=2.98, borderline, M=38.5, SD=7.0, and MMS, M=29, SD=15.25 (Proctor, Wilson, Sanchez, & Wesley, 2000).
Verbal discourse. Adolescents and young adults with TBI/ABI experience greater language dysfunction than young children who have experienced TBI/ABI. Young children, regardless of lesion site tend to compensate better than adults and have less morphological errors over time. This may be as a result of diminishing plasticity in adolescents (Stiles, Reilly, Paul & Moses, 2005).
Visual memory. The effects of early and late recovery of severe TBI/ABI were evaluated on visual and spatial memory in a study by Shum et al., (2000). Three groups of adult participants with TBI took part in the study. They included a severe TBI early-recovery group, a severe TBI late-recovery group and a control group who had no history of TBI. All participants were tested individually in one session on three different memory tests: The SVLT (SHUM Visual Learning Test), an electronic maze, and the RAVLT (Rey Auditory Verbal Learning Test). The control group obtained significantly higher scores on two indices of overall learning and the mean false-positive errors than the late-recovery and early-recovery groups (p<.01 for the mean false positives.
For the electronic maze, all participants were reported to follow the instructions and rules. The participants in the control group tended to make fewer errors than participants in the late-recovery and early-recovery groups. Participants in the late-recovery group tended to make fewer errors than the participants in the early-recovery group. The mean number of errors made by the late-recovery, early-recovery, and control groups were 7.637 (SD=5.802), 8.906 (SD=6.434), and 5.938 (SD=5.402), respectively.

Approaches
Positive behavioral supports may be needed to enhance the individual’s quality of life by addressing deficits in communication, psychomotor, cognitive functional outcomes, attention and executive function and memory (Ylvisaker, Jacobs, & Feeney, 2003).
Because of deficits in organizational skills students can facilitate their learning through the use of assignment sheets, tape recorders, calendars and self monitoring systems (Arroyos-Jurado & Savage, 2008). These can assist youth and young adults with organizing and maintaining their work-space and daily tasks. To determine which type of intervention that works bests for the individual, patient characteristics need to be taken into consideration. A review by Bajo & Fleminger (2002) examined evidence that patient characteristic may determine the type of intervention and rehabilitation effectiveness. The characteristics may include severity of injury, physical limitations, cognitive deficits and behavioral factors.
Approaches to management of acquired deficits that are driven the patient needs include two main categories. In a needs led service the importance is placed on identification of determining which therapy is most appropriate for the level of severity, the type of problem, the medical diagnosis, the level of rehabilitation readiness and any other demographic variables (Bajo & Fleminger, 2002).
The first category involves procedures, training, and implementation of strategies that can be used to improve restore of compensate for cognitive deficits, such as attention, memory, and executive function. These internally focused interventions are used by the individual with cognitive impairments to compensate for or lessen the functional impact of cognitive deficits. The second category utilizes externally focused interventions. These interventions are considered to be tools that are familiar to the general public and do not tend to be threatening or confusing to the patient (Wade & Troy, 2001). Ideally, external aids already in use should be incorporated into the overall assistive device planning. Some of the most popular devices include memory notebooks that may include calendars and daily schedules.
Internally focused interventions. Internal aids include techniques such as mental rehearsal, visual images, and mnemonics to assist memory or the comprehension of concepts (Wade & Troy, 2001). Rehearsal training is the process of repetition of information of information in working memory in order to enhance its consolidation into long-term memory (Dykeman, 2001). This training is based on the idea that brain-injured patients require direct, conscious rehearsal of information in order to ensure its consolidation. This has shown to be effective and easily taught for individuals with traumatic brain injuries and who demonstrate linguistic and cognitive impairments (Dykeman, 2001). Rehearsal is practiced in a variety of settings to improve its automaticity. This strategy does require training in identifying the material to be memorized or conscious use to ensure memorization but it does not demand that patients develop explicit mnemonics or other content-based methods.
Internal focused interventions or restoration techniques have as their goal the restoration of specific functions by retraining systems in the brain to take over for areas of lost cognitive function (Wade & Troy, 2001). This task may be accomplished through a technique referred to as drill and practice or having the individual practice or rehearse orally presented information (Dykeman, 2001). Drill and practice or rehearsal training is based on the premise that brain-injured patients require explicit, conscious rehearsal of information in order to remember it. This may be demonstrated by practicing phone numbers repeatedly until they can be retrieved from long-term memory. This rehearsal is, to some extent, an automatic unconscious process in normal function (Dykeman, 2001). Others have reported this to be an effective strategy for adults with TBI, however little data are reported to substantiate that conclusion.
A second restorative technique, called prospective memory training, requires the person to remember an activity to perform at a later time. These strategies include alarm watches, timers, and other electronic devices for providing reminders to perform activities at specific times. Some “voice memo” devices may record brief messages and can also be programmed to signal the patient to play back the recordings at specific times. Most electronic data storage devices first require programming by the therapist or caregivers for specific purposes for patients with memory impairments (Joode, Heugten, Verhey, & van Boxtel, 2010). These purposes ay include appointments, medication schedules, television schedules, phone numbers, and directions. Eventually, the patient may be taught to independently use the device and the stored information
Direct retraining of cognitive processes is a third type of internally focused intervention or restorative technique in the rehabilitation of some types of linguistic and cognitive impairments. It is based on the rationale that an individual’s memory will increase in accuracy with exposure as long as they begin to develop the use of more efficient strategies for encoding information. The development of efficient strategies occurs with experiences in memory tasks in the environment (Cobb, Sample, Alwell, & Johns, 2006).
Direct Retraining involves practice in the basic skills with feedback and reinforcement so that the individual improves in the use of that skill (Cobb, Sample, Alwell, & Johns, 2006). The patient is given a set of exercises in order to practice his or her memory skills. This process-specific training has been used effectively in attention training and recognizing stimuli that produce anxiety, stress, or violent responses but has had minimal effect on memory training. In a review of treatments for memory impairment, Cobb, Sample, Alwell, & Johns (2006) concluded that direct retraining may result in modest gains in memory skills. However, the intensity of training required to gain modest results suggests it is quite inefficient. Direct retraining does not facilitate generalization of skills to other areas. The subjects may be able to learn information in the clinical setting, but generalization to other tasks may depend upon the ability of the individual. Reasonable generalization may further depend on the subject having other intact cognitive skills such as processing speed and the ability to self-observe which skills are effective in order to generalize to other tasks (Arroyos-Jurado, Paulsen, Ehly & Max, 2006). However, no data has been found to support the use of direct training to facilitate generalization of skills.
A fourth technique, in the restorative approach, is the use of alternative functions that may involve teaching visual encoding strategies to an individual with verbal encoding deficits in order to concentrate on unaffected skill areas to compensate for deficit skill areas. The use of visual imagery may enhance aspects of episodic memory (Schmitter-Edgecombe & Anderson, 2007). This application of an alternate functional system uses strategies such as imagery, visual cuing, verbal cuing, verbal mediation (being given a third word that relates the pair), verbal mnemonics, paired associates learning tasks (word-word and face-name). Visual encoding strategies are taught to an individual with verbal encoding deficits in order to concentrate on unaffected skill areas. It has not been determined if the positive effects of word-word associations of face-name associations are specific to congruent areas of impairment or whether all impaired head injured subjects (children, adolescents, adults) would benefit from such treatments. A study by Schmitter-Edgecombe & Anderson (2007) using a Feeling of Knowing paradigm investigated the prospective and retrospective memory monitoring abilities of moderate to severe closed head injury patients. Their purpose was to monitor episodic memory during learning through the estimation of the likelihood that the patient would recognize a piece of information that they had failed to recall either from semantic memory or from recently learned episodic memory. Results of the study for the twenty-one individuals(age range 17-50) found that for episodic memory performance the mean proportion of cued recalled task words was significantly different for controls than the CHI group respectively: (Control M=.66, SD=.20; CHI M =.46, SD=.21, t(40)=3.13, p<.005). The mean proportion of successfully recalled target words was also greater for controls (Control M=.80, SD=.20; CHI M=.62,SD=.32,t(40)=2.13, p<.05). The findings indicated by the authors indicate that there is a significant difference between controls and individuals with closed head injuries in regards to episodic memory performance.
Externally focused interventions. The use of externally focused interventions is considered a functional approach and also termed compensatory intervention (Wade & Troy, 2001). They include externally focused approaches such as environmental modifications, changed experiences, and use of specialized teaching strategies (Arroyos-Jurado & Savage, 2008). The compensatory approach focuses on teaching real life skills utilizing alternative abilities that still exist, therefore, allowing the individual to perform essential activities. The skills may include tasks such as remembering a sequence of events to prepare for work or a set of steps to complete a daily task such as preparing a meal. Often this approach uses compensatory methods such as teaching a person to use a variety of tools such as a checklist or a daily planner.
Instruction and training in compensatory strategies provides the foundation for a portion of rehabilitation efforts (Arroyos-Jurado & Savage, 2008). First, external aids are objects that help people remember and organize their environments. External aids include electronic memory devices, alarms, calendar, visual reminders, and standardized locations for objects (Joode, Heugten, Verhey, & van Boxtel, 2010). Another name for external aids are assistive technology. These may also include pages, PDA’s, mobile phones and laptop computers. External aides also include the development of and compliance with daily routines such as going to the store, catching the right bus at the right time, and eating meals at set times. The use of note taking and recording information exchanges and delineating tasks to specific components are also considered external aids. There may also be external cues, such as a beeper, post it notes, and organized bulletin boards (Arroyos-Jurado & Savage 2008), or other devices that may serve to remind or cue the individual.
Hux, Bush, Zickefoose, Holmberg, Henderson & Simanek (2010) described memory notebooks or diaries as another memory aid. Memory notebooks are used as a system for organizing personal and scheduling information. Notebook contents may include calendars, daily schedules, medical information, things-to-do lists, and transportation information. In a study, as reported by Ownsworth and Mcfarland (1999), two different approaches to memory notebooks or diary training were evaluated with adults with acquired brain injury. (ABI). Twenty subjects were randomly selected from an interest questionnaire and divided into two treatment groups with 10 subjects in each. The majority of the subjects has sustained their injury from a motor vehicle accident with the average length of time since injury of fifteen years. The two approaches were identified as, diary only training and diary and self-instructional training. The training consisted of a six week time span for diary only training with two weeks of baseline and four weeks of training and six weeks of baseline with three weeks of training for the diary and self-instructional training group. The diary only training intervention was based on a bottom-up functional model of remediation. It emphasized development of the subject’s functional skills and the use of compensation devices based on task-specific learning. Subjects were taught a behavioral sequence of making a diary entry, checking the entry and using the information.
The diary and self-instructional training (DSIT) was based on a top-down model and emphasized training in the individual’s capacity for self regulation and self awareness. It was expected that this training would prove a systematic method to train a group of ABI (acquired brain injury) subjects on how to use a diary to compensate for memory problems. The patient was taught a self-instructional training (SIT) strategy that included W-what are you going to do; S-select a strategy for the task; T-try out the stragtegy; C-check out how the strategy is working (WSTC). The diary was a lined red exercise book and the typical features of a diary were included (e.g. an address and personal information page) as well as a list of key prompts for each calendar day. The eight prompts corresponded to typical memory problems that included how distressing the memory lapse had been and ratings of helpfulness of strategies. The percentage of total diary entries made was calculated for each of the four treatment weeks.
The results suggested that the subjects who were taught the diary and self-instructional training method maintained their use of the diary strategy to a greater extent than the diary only subjects. The with self-instruction training (M=28.7, SD=36.7) made more diary entries than the diary only group (M=19.8, SD=20.4) across the four week treatment program. Furthermore, diary only group made significantly fewer entries during the first and second week. The diary with self-instruction training maintained their use of the strategy longer than the diary only group.
External aid training requires patient participation and investment in the process, as noted by de Joode, Heugten, Verhey & van Boxtel, (2010). When external aides are used they should be chosen based on the adolescent or young adult’s strengths. Students and adults need to be encouraged to review the schedules a day in advance, to help prepare for the next day’s events. Initially, a parent, teacher, or caregiver may help in preparing the schedule by listing with the youth the activities of the day, or develop a checklist that lists activities to “check off” as completed or develop a format or routine that best suits the individual’s needs.
One of the latest forms of electronic, external memory aides is the palmtop computer. Several reasons for the usefulness of microcomputers for TBI patients are identified (Kim et al., 1999; Wright et al., 2001). First a higher level of independence may be achieved through the use of self-initiated activities. Second, there may be an increase in the patient’s self-esteem and life satisfaction. They may accomplish tasks quicker, with greater independence, which in turn leads to a better feeling of self-worth. And last, they are potentially cost-effective. By assisting with community and vocational re-entry, the use of a palm computer may shorten the length of the rehabilitation program and reduce the need for individual personal aides.
Results from a study of a 22 year old head injured adult male demonstrated deficits in memory, executive functioning and cognitive-linguistic deficits found that palmtop computers are useful in improving functional memory. Initial cognitive scores fell below the borderline range for his age. On the WAS-R, a score of 58 on Verbal IQ was reported, as well as 57 on Performance IQ, and 53 at Full Scale. At initial orientation of a memory notebook he was rated as needing “maximum cues” for all aspects of his schedule. A palmtop computer was introduced with therapy schedules entered and medication schedules introduced five days later. The subject was able to maintain all schedules at 100& on the first day. No data for generalization or maintenance were given (Kim et al., 1999). Furthermore, field trials of palmtop computers with mildly impaired brain injured patients indicated that 65% of these memory impaired individuals found them to be sufficiently effective to adopt usage of these device on an ongoing basis.
A study by Kim et al. (2000), on the utility of palmtop computers for individuals with TBI and CVA (cerbrovascular accident) was conducted as a follow-up to the previous study by Kim et al. (1999). Eleven outpatients with TBI and one with CVA were included in the study after being identified with functionally, disruptive impairments of prospective memory.
The subjects comprised of eight men and four women, ages 22-67 years. All were independent in self-care and community facilities at the time of computer introduction.
The follow-up study was initiated two months and four years after initial training and trial usage. The patients were surveyed by phone on the utility of the computer for assisting with memory dependent activities. Subjects were asked whether the device was useful, how often they had used it, and whether they still used utilized the computer and/or any other memory aid.
Results of the study indicated that out of the twelve patients, nine (75%) reported at follow-up that the computer had been useful on a daily basis. Out of the nine patients, seven (77.8%) reported that they continued to use the palmtop computer even after the completion of the supervised trial. Four of the seven had palmtop computers purchased by their insurance companies, the remaining three purchased devices on their own.
Mobile phones as a memory aid were investigated for traumatic brain injured patients for their effectiveness to minimize the effects of everyday memory problems. Wade & Troy (2001) studied five participants to demonstrate that the system of using a mobile phone was effective for increasing various self-initiated behaviors such as taking medications, brushing teeth, going to work, make packed lunch, etc. The findings of the study indicated that the mobile phone benefited every participant for everyday memory problems as well as for planning and organization. Four out of the five participants reached 100% for target goals for all self initiated behaviors.
Individuals who are digitally connected through the use of the of the internet have opportunities to obtain information, send messages, chat instantaneously, enact banking and personal interactions, join online support groups and seek employment (Egan, Worrall & Oxenham, 2005). Barriers for individuals with traumatic brain injuries using the internet include cognitive impairments, psychosocial barriers, technology design barriers, training barriers and memory and attention deficits.
In a study by Egan, Worrall, & Oxenham, (2005) individuals with TBI were evaluated to determine if they could learn to use the Internet using specialized training materials. Seven participants were taught on four modules that incorporated 12 internet tasks that were explained in a step-by-step method. The tasks were organized in difficulty level from least to the most cognitively challenging beginning with turning on the computer and ending with printing a page and shutting down. Progress was recorded on a 5 point Likert scale assessment that measured baseline and levels of change. For the Internet skills assessment group means showed a post-test rating of moderate-to-total independence on all tasks. For six of the seven participants gains in independence were significant (z=-2.201, p=0.028). The authors also noted from their findings that greater gains were made in independence on tasks which placed less demand on working memory, cognition, and language ability.
Other research has examined the research of different types of pocket computers such as palm pilots, cell phones, smart phones, and PDA’s. These devices are useful in the daily management of memory, planning and organization of events. Joode, van Heugten, Verhey & van Boxtel (2010) reviewed twenty eight papers that involved studies on reports regarding the efficacy of portable electronic aids for individuals with cognitive deficits. As a result of their literature review the authors concluded that the Neuropage which is a paging system designed to alert the individual using a scheduled reminder was effective for assisting patients with taking their medications on time. Cell Phones and smart phones could be considered as a memory aid if the user is willing to utilize the device. Other advantages of the cell phone include calling capabilities in case of emergency and tracking of the individual if they become lost.
The challenges and variety of impairments that adolescents and young adults face necessitates establishing supportive environments and appropriate accommodations in order for them to succeed in the academic arena and with functional skills (Hux, Bush, Zickefoose, Holmberg, Henderson, & Simanek, 2010). To integrate these students into the high school and college setting the strategies that may be utilized include the use of memory notebooks, academic planners, assisted note-taking, mnemonic devices, and the allowance of personal technology devices such as PDA’s , mini computers, I-Pads, etc. in the school environment.

Intervention

Introduction
Adolescents and young adults who have sustained a traumatic brain injury endure cognitive deficits that are positively correlated with the severity of the injury, therefore increasing the need for rehabilitation strategies and special education services. It has been well documented in the literature that TBI in children and youth is often associated with working memory impairments as well as other social and general cognitive deficits (Stapleton, Adams, & Atterton, 2007).
Individuals with traumatic brain injuries demonstrate more prospective memory problems than people without brain injury according to Stapleton, Adams, & Atterton (2007). These difficulties affect activities of daily living and the ability to perform tasks at a future point in time.
Guidelines set by the European Neurological Societies for the clinical effectiveness of cognitive rehabilitation and stroke is similar to the recommendations set forth by the Brain Injury Interdisciplinary Special Interest Group (BI-ISIG) of the American Congress of Rehabilitation Medicine (ACRM) (Stapleton, Adams, & Atterton, 2007). Both of these groups encourage electronic memory aids as having the strongest evidence of effectiveness for traumatic brain injured individuals. The BSI-ISIG recommends training in external compensations including assistive technology which includes cellular phones to increase functional activities.
To meet the needs of youth and young adults with memory impairments, rehabilitation strategies must be used that adjust for ability, age, and severity of injury. Pre-injury factors such as intellectual and academic functioning should be taken into account when evaluating outcomes following injury (Arroyos-Jurado, Paulsen, Ehly, & Max, 2006). Compensatory techniques target the individual’s ability to improve in certain activities and participate in socially accepted behaviors (Stapleton, Adams, & Atterton, 2007).
The use of external memory aids has been shown to lessen the overwhelming effects that memory impairment can have on a young adult’s life. These are used to improve independence and therefore create a quality of life that is valued by the individual. Electronic aids such as personal computers, personal digital assistants and cellular phones support cognitive activities by helping individuals to manage their daily lives (Joode, Heugten, Verhey & van Boxtel, 2010). Daily activities that may be enhanced include memory, planning for the day or week, remembering appointments, keeping contact information organized and keeping track of notes.
One of the most appealing reasons for examining the use of mobile phones to provide memory prompts for individuals with brain injury is that they represent the fastest growing market in communication technology. In the past eight years the number of cellular subscribers has increased nearly 25% annually, reaching 60% of the total population according to the Head of the United Nations International Telecommunications Union (Bilello, 2008). The mobile phone has certain advantages over other individual communication technology systems such as pagers which include the size of the screen leading to poor message/background contrast (Wade & Troy, 2001). The mobile phone also has spoken message capabilities which allows for use with individuals with poor reading abilities or acquired dyslexia.

Project Purpose
The aim of this project is to determine if the mobile phone is an effective memory aid, user friendly and has potential to be used by youth and young adults with traumatic brain injuries in the academic setting. Advances in mobile phone technology allow for “reminders” such as alarms and scheduled calls. These functions allow messages to be pre-programmed that remind individuals to complete a task in the future at a specific time (Stapleton, Adams & Atterton, 2007).
Direct application of the external aid is recommended for functional activities that the youth and young adult face on a daily basis. This study will be designed to compare self-initiated performance in remembering to carry out target tasks both prior to and with the mobile phone.
The target population of youth and young adults with traumatic brain injuries are known to face many challenges when they return to school after injury. There are many misconceptions about these youth and their school problems that educators and school personnel are known to have (Farmer, Johnson-Gerard, 1997). It is imperative that both rehabilitation specialists and educators understand factors and the importance of interventions for these youth.
Traditional classroom and school environments at the high school and college level require students to function independently. Students with cognitive impairments such as memory deficits have options to aid in self-management. External aid modifications such as tape recording and memory notebooks have been researched in the literature as compensatory strategies (Dykeman, 2001). The use of the cellular phone to aid in prospective memory also has benefits for these individuals. When developing the individualized educational program for these students the cellular phone should be considered as an accommodation that is required for success.

Elements of the Intervention
Eligibility. To determine eligibility for the study a clinical and record review will be conducted to determine medical identification of TBI/ABI. Classification of a traumatic brain injury refers to a physical injury to the brain. Severity of injury will be determined using the Glasgow Coma Scale and/or duration of loss of consciousness (Hawley, Ward, Magnay, & Mychalkiw, 2004). General impairments in verbal memory and language are often represented by cerebral dysfunction with TBI (Rourke, Ahmad, Collins, Hayman-Abello, & Warriner, 2002).
Target Population. Students ages 13 to 23 who have been identified as having memory impairment after a traumatic brain injury, and for whom a memory aid was deemed appropriated will be approached for the study. All individuals selected will have previous history of at least one year of head trauma and been offered medical follow up. To be chosen, all participants will demonstrate memory impairments in everyday living and have difficulty carrying out tasks independently. Participants for the study also must have the ability to read a message on the mobile phone screen. Individuals who are not capable of this task will be excluded.
All individuals to be included are to live with a responsible caregiver. This is to ensure that recordings of memory activities are completed by someone other than just the student. Other exclusionary factors include the current use of an appointments function on a mobile device as a memory aid and individuals with evidence of a degenerative neurological condition (Stapleton, Adams, & Atterton, 2007). Individuals will also be excluded if they are already receiving any other therapeutic interventions for memory problems as these may interfere with findings.
The students will be selected from a local school district that includes one high school, one alternative school, and one rehabilitation center. Students who are graduated from high school will be selected from the surrounding local community colleges.
Target behaviors. At the beginning of the study the participants and their caregiver will be interviewed to identify the most appropriate types of activities that they forget to complete on a daily basis. The face-to-face interview will be conducted at a location that is designated by the caregiver. An informal conversational interview format will be used to discuss targets that are most important. Open ended questions that allow for free response from the client and the caregiver will elicit the best responses and clearly identify the targeted behaviors.
A prioritized list will be compiled from most to least important. The individual will also be asked whether they wish to be prompted in order to engage in the activity independently or would they rather be prompted by their caregiver. These listed activities are considered “target” behaviors. A personal questionnaire will be designed based on these targets to measure everyday success.
Memory success will be recorded on the target behaviors each day by the individual and the caregiver. The use of both recordings will help eliminate difficulties with memory and forgetting to make entries by the TBI client. Recordings are made by checking off boxes and/or writing specific times, where appropriate on the personalized questionnaire.
Baseline data. Baseline measurements will be taken for each subject using diaries/checklists for caregivers to record performance over a two week time period. Baseline data is needed to compare with the intervention data in order to determine if any change has taken place and if the change is due to variables other than the intervention such as technology malfunction, loss of phone, etc.
Text message intervention. The reminders function will consist of presenting a written reminder text message on the mobile phone at the time and day that has been specified. These will include messages that have previously agreed on by the subjects, and caregivers that are most needed and appropriate. They may include medication reminders, daily class schedules, books and homework check before leaving school, and which bus to take to get home, etc. The messages will be brief with a limited number of words for each message to promote understanding (Stapleton, Adams, & Atterton, 2007).
Each message will be accompanied by a ring tone that matches the message. Each message will be identified that it is a pre-recorded message to keep it from being confused with other messages (Stapleton, Adams & Atterton, 2007).
Reminders can be set by using the “add an event” function on the mobile phone. This can be accomplished through a series of steps that include titling, selecting the date and time, and checking whether the event is a recurring event. To respond to the event notification the individual will touch yes, or no to indicate whether or not he/she has received the message and is completing the task (Johnson, 2011).
After 10 weeks with the phones, the phones will be removed and the diaries will be given back to the clients/caregivers for two weeks to reestablish baseline and measure change in performance.

Potential Contributions
Indentifying change. Using a multiple baseline approach, the project may contribute to determining which behaviors change significantly whenever the treatment is implemented. For example, baseline measurements will be recorded on two or more discrete, independent behaviors for one subject such as check off daily calendar reminders, and the use of text messages for medication schedules. A strong causal influence can be made of the effect of the treatment if performance shows consistent change after the treatment is introduced for each type of behavior (McMillan, & Schumacher, 2000).
Implications for students. The mobile phone has the potential to increase independence which can in turn reduce stress and frustration for the caregiver. Secondary contributions include the use of the phone for emergency contacts and as a communication tool.
Implications of these outcomes include helping students reintegrate into the general curriculum as well as offering guidelines on best practices regarding service delivery to students who have sustained a brain injury. Future research may include a focus on the use of technology with a larger controlled trial. Memory impairments that are associated with other types of disabilities such as learning disabled or mentally impaired may also be included in a follow up study.

Implementation
Design. The proposed intervention using cellular technology is intended to increase student functional independence by targeting specific tasks for each individual student. Change in behavior will be documented using a checklist system kept by the student or caregiver depending on the age and capability of the individual. To check for reliability a pre/post test measure will be utilized. A high degree of stability within the cellular phone will indicate a high degree of reliability and will indicate that the results are repeatable (Golafshani, 2003). Validity is measured by the accuracy of the cellular phone and whether the intended targets are actually measurable.
Using a single subject research design, evidence of improved functional memory skills for adolescents and young adults with TBI will be examined. A major advantage to this type of research is its ability for isolating the cause of behavior change as a result of interventions that
have been put into place (Foster, Watson, Meeks, & Young, 2002). The design of this program is an A-B-A design where baseline is first determined, followed by intervention, and a second baseline period for comparison to intervention.
The study will also use a multiple-baseline across participants approach. This will allow for the collection of data for all target areas for each participant. The design will address the impact of the treatment of the independent variable (mobile phone) on the dependent variables for different participants (Barger-Anderson, Domaracki, J., Kearney-Vakulick, & Kubina, 2004).
Structure. A flow chart that describes the steps of this process is provided to guide the structure and development of this framework.
Obtain consent
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Determine targets
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Define targets in observable terms
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Instruct on self assessment process
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Keep baseline data for 2 weeks
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Input text messages in phones
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Introduce/teach phones and data collection process
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Collect phones and data after 10 weeks
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Return to diary self assessment for 2 weeks for comparison
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Compile data/Report results

Consent. After having received initial consent for participation all potential participants will be visited at home and told about the mobile phone project in detail (Wade & Troy, 2001). They will receive an information sheet and if they (their parents) agree they will be asked to sign a consent form. Mobile phones will be agreed on and loaned to the participants in the project. If any individual wishes to use their own phone they may do so.
Determination of targets. At the beginning of the study the participants and their caregiver will be interviewed to identify the most appropriate types of activities that they forget to complete on a daily basis. A prioritized list will be compiled from least to most important. These listed activities are considered “target” behaviors. The individual will also be asked whether they wish to be prompted in order to engage in the activity independently or would they rather be prompted by their caregiver. A personal questionnaire in the form of a diary will be designed based on these targets to measure everyday success.
Diary assessment. The first step of diary assessment is to select the target behaviors. Once these are identified they should be defined precisely in observable terms. References to internal processes such as understanding or appreciating will be avoided. Examples of the target behaviors will include both subtle descriptions and non-instances of the behaviors.
The second step will be to clarify with the student and caregiver how to use the self-assessment process and the rating scale. The recording of observations will consist of using codes for each target such as “code 1” for taking medication, etc. Training in recording of observation will include how to record the behavior, and practice using the observation system. Training will be continued until a consistent level of accuracy is reached. Observer’s accuracy will be evaluated by comparing their responses to each other’s. A high agreement is required before an assumption can be made that the observer is ready to conduct observations independently.
The client and caregiver will record correct and non-correct responses of identified targets that are remembered independently before the introduction of the phones. Recordings are made by checking off boxes and/or writing specific times, where appropriate on the personalized questionnaire.
Observations on the target behaviors will be recorded each day by both the individual and the caregiver. The use of both recordings will help eliminate difficulties with memory and forgetting to make entries by the TBI client. The diaries will be kept for a period of 2 weeks prior to the introduction of the phone use.
Introduction of the mobile phone. After the baseline measurements have been established, the wording and timing of the messages will be discussed. Relevant text messages will be inputted into the phones following baseline.
The reminders function will consist of presenting a written reminder text message on the mobile phone at the time and day that has been specified. These will include messages that have previously been agreed on by the subjects and caregivers that are most needed and appropriate. They may include medication reminders, daily class schedules, books and homework checks before leaving school, and which bus to take to get home, etc. The messages will be brief with a limited number of words for each message to promote understanding (Stapleton, Adams, & Atterton, 2007).
Each message will be accompanied by a ring tone that matches the message. Each message will also be identified that it is a pre-recorded message to keep it from being confused with other messages (Stapleton, Adams & Atterton, 2007).
Return to baseline. After 10 weeks of collecting data the phones will be collected from the clients and the diaries/self-assessments will be returned. After two weeks of data collection on the same targets the diaries will be collected for comparison with initial baseline and intervention. A causal inference can be made if the patterns of behavior change during the treatment phase and then returns to about the same pattern as observed in the first baseline after the treatment is removed.
Reflections/Conclusions
Brain injury rehabilitation is most effective when the treatment is based on individual patient needs rather than on certain standards of criteria. Using a needs led service encourages the importance to begin with the characteristics of the individual and identify which therapy or intervention is best suited for their needs. Individuals who have been brain injured often have needs focused around six levels. These include level of severity, type of presenting problem, past medical diagnosis, level of rehabilitation readiness, demographic variables, and geographical and social factors (Bajo & Fleminger, 2002).
Student survivors of TBI/ABI often display learning skills differently than their younger counterparts (Hux, Bush, Zickefoose, Holmberg, Henderson & Simanek, 2010). As a result of this they are in need of more advanced strategies to support their academic and functional performance as well as social integration. The purpose of this study was to investigate technological accommodations to facilitate high school and college success. The use of the mobile phone as a compensatory aid may lead to promising outcomes for students with TBI/ABI for increasing functional independence.

Practitioner-Researcher Attributes/Goals
Professional attributes. Combining research and practice involves careful and critical examination of natural events that allow for testing of theories. Investment in education and training is necessary to be qualified to develop and test programs that affect and change individual behavior (Brown-Urban & Trochim, 2009). By focusing on effective implementation strategies and appropriate matching goals the practitioner-researcher is able develop programs matched with client needs. The practitioner may be faced with ever-changing needs of their clients which will generate circumstances for basing their judgments on intuition rather than tested theories.
Theoretical orientation. Theory driven evaluations are based on offering services to people in need. In this way, the services are expected to change the individuals specified. The analysis of the program consists of discovering relationships between services and characteristics of patients and among services and immediate changes as well as among immediate changes and outcome variables. Correlational techniques are used to determine associations among variables (Brown-Urban & Trochim, 2009).
Culturally skilled practitioner. A review of the literature suggests that to be a culturally skilled practitioner one must be adept in skills of problem solving in areas that involve interpersonal relationships and face to face behaviors. The effective practitioner should be able to communicate ideas and inspire others to follow positive ideals. They should be able to demonstrate empathy as well as display open and genuine relationships with their clients (Fisher, 2010).
Keeping up with current trends and traditions is an important aspect of the well rounded practitioner. They should be able to recognize the importance of setting personal and organized goals that will benefit not only the client but are also important for a positive team culture. (Fisher, 2010).
Ethical dilemmas. Having an ethical commitment means that you are aware of your beliefs, and life commitments. You are leading the best, most consistent ethical life that you can. As a psychologist in the field, having this type of commitment means that you strive to follow the general principles set forth by the American Psychology Association of Beneficence and Nonmaleficence, Fidelity, Integrity, Justice, and Respect for persons (American Psychology Association, 2002). These ethical commitments reflect character and virtues. They are described as honesty, trust, fairness, respect, integrity, and responsibility.
Professional ethics is an involved system for students, teachers, and practitioners. This system begins with the Standards that were created by the American Psychological Association. They provide guidance for individuals who are in the psychology, counseling, and assessment fields (Hill, 2004). They are designed to assist psychologists and others in the field to take an ethical course of action (American Psychology Association, 2002). In the Evaluation Testing and Measurement field ethics are as important to the psychologist as in the counseling field. Test users have ethical responsibilities as well as responsibilities to the individual being tested. These guidelines apply not only to psychological tests but to educational assessments as well (American Psychological Association, 1999).
To have moral behavior, as described by Hill (2004), the behaviors that a psychologist should demonstrate include moral judgment (deciding which actions are right or wrong), moral motivation (prioritizing), and moral character (having courage to stand up for your convictions).
The ethical analysis of Utilitarianism, Kant’s Formalist Theory, and Ethical Contextualism establish decision making processes for psychologists to resolve this dilemma. Utilitarianism exemplifies the position that the ethical obligation depends on the ultimate goal of providing pleasure or pain. The Formalist theory supports the conclusion that duties are universal obligations that must be fulfilled. The concept also reflects the idea to treat others as you wish to be treated. Ethical Contextualism emphasizes the principle of adaption of ethical guidelines to personal situations (Ford, 2006).
As an educator, solving ethical dilemmas is a challenge in the school setting. In recent research the ethical decision making models have involved an ethical analysis approach that focused on counseling ethics. While some educational dilemmas overlap some are unlike those of the counseling profession.
Diverse/Multicultural views. Being cognizant of world views will assist the psychologist in understanding the variety of views that are involved in formulating their goals and needs. Being cognizant facilitates the development of treatment needs and goals. (Buhin, 2004).
To increase knowledge of the world and multicultural issues, a process of critical inquiry should be implemented. Before entering into a multicultural relationship with a client it is important to be informed of that particular cultural heritage. This knowledge can be increased through books, videos, workshops, and culture-specific community events (Buhin, 2004).
In the testing field the System of Multicultural Pluralistic Assessment (SOMPA) is used as an evaluation tool for minority groups, especially Hispanics (Kaplan & Saccuzzo, 2009). One of the major philosophical assumptions according to Kaplan and Saccuzzo (2009) is that all cultural groups have the same average potential. Differences among these groups are assumed to be caused by differences of access to cultural experiences. This assessment recognizes that various subcultures are associated with different life experiences. Along with the WISC IV, the SOMPA provides information regarding multicultural relationships.
The protection of individual rights is another issue that needs to be studied. It applies not only to special education students but also to clients within a psychology relationship. The concept that individuals have the right to pursue their own good falls under the principle of respect for people’s rights and dignity under the APA code of conduct (2002).
People are essentially encouraged to be socially accepted. We live in communities that provide languages, meanings and values in order for us to understand our world and culture. Because of this sense of identity we have a greater sense of responsibility and duty toward the communities and cultures that we belong to (Kaplan & Saccuzzo, 2009).
This dilemma leads to an ethical problem that psychologists should attempt to eliminate the effect of bias based on their own goals and cultural differences. By protecting the rights of their clients, precautions should be taken to respect cultural, individual and role differences. These precautions will insure that their biases don’t interfere or lead to unjust practices (American Psychology Association 2002).
The high ethical standards of publishing, research, test administration and scoring, test use, and unbiased practices in testing practices and research dictate the commitment level of the psychologist. By following the standards set forth by the APA and National Council on Measurement in Education these requirements support the premise of the acquisition of knowledge, skills, and abilities that benefit the testing process. Training in specific tests are a main part of the process as credentialing for testing purposes is mandatory (American Psychological Association, 1999).
Another issue that is important in the field of testing is the trend of movement toward increased protection for public and testing laws. Most states have current laws regarding the use of psychological tests. States also have regulations regarding the qualifications of testing administrators that will reduce the chance that an unqualified professional will administer a test. Knowledge of all of these laws and guidelines is necessary for an effective and ethical practice.

Action plan

Strengths
Ethical principles. Strengths are present in the ethical principles that are applicable to academic and professional activities. These include strengths in an increased awareness of personal values through critical assessment and a development of a clearer understanding of the role values play in professional conduct (Ford, 2006). Rehabilitation specialists utilize ethical guidelines while implementing treatment plans for individuals with TBI/ABI in the areas of cognitive behavior therapy.

Developing competence. Following specific guidelines set forth by the ethical standards to maintain high levels of competence is paramount. Sufficient training in the specialty area to provide competent service is necessary (Ford, 2006).
Respect for individual differences. Within the field of education and testing and measurement individual rights should be respected including their rights to make their own choices and controlling their own actions and how they want to live their own lives (Ford, 2006).
Limitations
Application of theory. Theories which inform research may direct the focus of the expectations of the framework. We use theories to predict what will happen in the future. Developing an understanding of the multiple types of theory structures that have to be tested using different types of research methods is a limiting factor. The nature of the theory limits the range of research methods which can be meaningfully used to test it (Breakwell, Hammond, Fife-Schaw & Smith, 2006).
Communicate effectively. Interpretation of the data and reporting of the findings is the most important part of the research process. The data should be presented in terms of the problem, codified, arranged and separated into groups which correspond to particular parts of the problem being studied (Leedy, & Ormrod, 2005). Describing the data in analytical terms is recognized as an area worthy of further practice.
Goals to Build on Strengths
Psychological standards. Utilize psychological standards to assist in day to day evaluative decisions and maintain knowledge regarding skills and abilities regarding procedures and personal ethical responsibilities (American Psychological Association, 1999).
Peer reviewed articles. Review peer reviewed articles for merit. Evaluation of articles for merit involves identifying deficiencies and screening for technical results.
Diversity. Consider all backgrounds and disabilities when testing including linguistic backgrounds and special needs populations. This includes students in special education classrooms as well as clients with different cultural backgrounds.
Goals to Build on Limitations
Differing theories. Research different theories regarding educational psychology for applied research. Utilize research libraries to search and expand knowledge regarding theories and testing.
Report quantitative findings. Further develop skills in reporting quantitative findings. Study quantitative methods for reporting findings.
Strategies to reach goals.
As short-term goals develop into long term goals they can be refined into more meaningful consistent aspirations. By filling in gaps and resolving inconsistencies a deeper understanding of the subject matter can be achieved. Adding to and building links between new information will assist in widening the knowledge base. This will lead to the development of interests in new tasks and subject matter. The use of strategic thinking to reflect on methods and theories can be utilized to reach learning and performance goals and to monitor progress. If progress toward the goals is not being met then alternate methods can be generated (American Psychological Association, 1997).
To reach all goals a timeline should be set that includes which deadlines are appropriate for each goal. Each strategy should be broken down into workable parts as a task analysis and into weekly or monthly activities. The list should be revised as it is accomplished to ensure priority maintenance.
Synthesis of Coursework
Skills included in program. Included in the coursework is the development of skills needed to anticipate the impact of diversity programs and evaluate their effectiveness by applying principles from psychometrics and social psychology. Psychometrics is utilized to assess organizational performance, structure, and strategic progress for program evaluations. Statistics are used to produce concrete measurable results.
Career Expectations and Plans
Contributions of educational measurement specialists. An educational measurement specialist may be involved in many aspects of school improvement and educational programs in schools, colleges, and universities and other educational settings such as testing centers. As a specialist in the field a direct impact may be made on individual students by assessing their needs and providing information to state or local policy-making bodies that may lead to increased effectiveness and greater accountability (NCME, 2010).
Application of educational measurement. Public agencies such as federal and state testing groups as well as research organizations utilize educational measurement specialists. Also, colleges and universities, school districts, and the military are making increased use of educational measurement. Many major publishing companies employ specialist to evaluate and monitor textbooks, achievement and aptitude tests, college entrance examinations, and other specialized evaluation instruments (NCME, 2010).

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