Training Assistive Technology for Cognition

Post-ABI:Results of a randomized

controlled trial

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Laurie Ehlhardt Powell, PhD, CCC-SLP

Ann Glang, PhD, Debbie Ettel, PhD, and Bonnie Todis, PhDCenter on Brain Injury Research and TrainingTeaching Research Institute, Western Oregon University

McKay Sohlberg, PhD and Richard Albin, PhDUniversity of Oregon, College of Education

Project funded by NIH-NICHD Award #5R03HD54768

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What is Assistive Technology for Cognition (ATC)?

High tech electronic memory aids:Examples• voice recorders; personal digital assistants;

cell phones; smart phones

• useful for programming repeated entries and providing external cues to prompt task performance

• customizable & off-the-shelf

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Why Focus on “Training” (Instruction)?

Under-utilization and abandonment of ATC often due to:

•Assessment (poor match)

•Funds (can’t afford)

•Training (little or no training)

default to trial-and-error learning

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Instruction Literature:Snapshot #1Neuropsychological Rehabilitation Focus - minimizing errors during delivery

of instruction:

▫Errorless learning▫Spaced retrieval

Most helpful for individuals with more severe cognitive impairments.

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Instruction Literature:Snapshot #2Special Education

Focus - comprehensive design AND delivery of instruction

Systematic instruction• multiple components• includes errorless learning, spaced retrieval

Helpful for learners from a wide variety of backgrounds.

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Research QuestionsDoes systematic instruction (SI) vs. conventional instruction (CI) (trial-and-error learning) applied to ATC result in:

1. more accurate performance at post-test?

2. better maintenance at 30-day follow-up?

3. more efficient (fluent) performance?

4. better generalization?

5. higher satisfaction ratings based on post-training surveys? (non-experimental)

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MethodsParticipants

• 45 adults with ABI screened

• 32 met selection/exclusion criteria; entered into study

• 29 completed study (15 SI: 14 CI)

• moderate-severe cognitive impairments due to ABI

• 17 males and 12 females (M= 42.31 yrs; range 20-68 yrs)

• Disability Rating Scale (DRS) (M=5.5 SI; M = 5.7 CI)

• Neuropsych testing for descriptive purposes

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MethodsResearch Design

•Double-blind randomized controlled design

•Participants, evaluator, & coders blind to study condition

•Trainer (PI) and fidelity checkers not blind to condition

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MethodsTraining

•Pre-test

•Training applied to Palm Tungsten E2 PDA

-12 individual sessions, 45 min each, 2-3x per week, 4-6 weeks

•Post-test

•30-days post (maintenance)

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Independent Variables (Training Conditions)

Systematic Instruction Conventional

Instruction

Limited range of instructional targets (calendar program only)

Broad range of instructional targets(calendar program plus )

Multiple training examples Few training examples

Mastery emphasized Mastery not emphasized

Exploration discouraged Exploration encouraged

Step-by-step models; carefully faded support Whole task model only

High rates of correct, distributed practice and review per target

Few practice opportunities per target

Immediate corrective feedback Wait to give feedback

Training in different environments Training in clinic setting only

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MethodsTreatment Fidelity (IV) &Inter-rater reliability (DV)

Fidelity checks: •3 of 12 sessions for each participant (87

checks total)•distributed over their 4-6 week course of

training• few instances of lack of fidelity

Inter-rater reliability:• 90% average across pre-post & 30-day

checks.

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Dependent Variable (Outcome Measure)Pre, Post, and 30-days

Sample Tasks

Type TaskPerson/Environment

Checking information – calendar program

“What is your first appointment tomorrow?”

Evaluator – quiet space

Entering information – calendar program

“Enter this doctor’s appointment.” Evaluator – quiet space

Checking information – calendar program

“What is your next appointment today?”

Another person/environment

Checking information – calendar program

“Enter your next appointment with us.”

Another person/environment

Entering information- tasks program (generalization)

“Enter this new item on your task list”

Evaluator – quiet space

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MethodsPsychometrics & Group Equivalence

Outcome measure (DV)

• good internal reliability (Cronbach’s alpha = .915)

Groups were generally equivalent across several key indices:

•Pre-test performance on DV

•DRS

•Demographics (age; education; SES, etc)

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ResultsQuestions 1-3

1) Accuracy at Post-Test: No significant differences between groups; p = .115

2) Accuracy at 30-Days (maintenance): Significant differences in favor of SI

p=.005; ES=1.44 (very large)

3) Fluency (Post & 30-Days): No significant differences at post-test; significant differences at 30-days in favor of SI

p= .051; ES = .76 (large)

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ResultsQuestions 4 & 5

4) Generalization:

Significant differences for items taught across environments; in favor of SI (post-test only)

p= .048; ES = . 80 (large)

5) Social Validity (non-experimental):

No clear differences between groups; the majority of the participants “agreed” or “strongly agreed” with evaluator questions concerning the benefits of the training received

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PretestPosttest

Follow-up

0

1

2

3

4

5

6

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CONVENTIONAL

SYSTEMATIC

6.62

4.25

5.07

6.86

1.67

2.29

ANCOVA ResultsSignificant difference in mean # tasks correct, controlling for pretest level (Total # of tasks = 10)

Maintenance

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PosttestFollow-up0

10

20

30

40

50

60

70

SystematicConventional

Secon

ds

Difference

ResultsFluency (Seconds per correct task)

Conventional and systematic instruction fluency (seconds per correct whole task) were not significantly different at posttest, but fluency was significantly better for systematic instruction participants at follow-up (t = 2.074, p = 0.051). ANCOVA was not possible for fluency due to limited data on rate at pretest.

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Clinical Implications Research

•Fewer, systematically taught training targets results in better maintenance.

•Replicate study with higher number of participants, different technology and trainers.

•Current project developing “trainer friendly” materials for instructing use of assistive technology (NIDRR TATE Project Award# H133G090227)

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Selected References• www.ancds.org “Practice Guidelines”

• Ehlhardt, L.A., Sohlberg, M.M., Glang, A., & Albin, R. (2005) TEACH-M: A pilot study evaluating an instructional sequence for persons with impaired memory and executive functions. Brain Injury, 19 (8), 569-584.

• Ehlhardt, L., Sohlberg, M.M. et al. (2008). Evidence-based Practice Guidelines for Instructing Individuals with Acquired Memory Impairments: What Have We Learned in the Past 20 Years? Neuropsychological Rehabilitation, 18 (3), 300-342.

• Sohlberg, M.M. & Turkstra, L. (in press). Cognitive Rehabilitation: Teaching New Skills, Strategies and Facts to People with Acquired Brain Injury. New York: Guilford Press.

• Sohlberg, M.M., Kennedy, M.R.T. et al. (2007). Evidence based practice for the use of external aids as a memory rehabilitation technique. Journal of Medical Speech Pathology, 15(1)

• Stein, M.S., Carnine, D., & Dixon, R. (1998). Direct instruction: integrating curriculum design and effective teaching practice. Intervention in School and Clinic, 33, 227–234.