Training Assistive Technology for Cognition Post-ABI: Results of a randomized controlled trial 1

Laurie Ehlhardt Powell, PhD, CCC-SLP Ann Glang, PhD, Debbie Ettel, PhD, and Bonnie Todis, PhD Center on Brain Injury Research and Training Teaching Research Institute, Western Oregon University McKay Sohlberg, PhD and Richard Albin, PhD University of Oregon, College of Education Project funded by NIH-NICHD Award #5R03HD54768

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 3

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 4

Instruction Literature: Snapshot #1 Neuropsychological Rehabilitation Focus - minimizing errors during delivery of instruction: ▫Errorless learning ▫Spaced retrieval Most helpful for individuals with more severe cognitive impairments. 5

Instruction Literature: Snapshot #2 Special 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. 6

Research Questions Does 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) 7

Methods Participants 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= yrs; range yrs) Disability Rating Scale (DRS) (M=5.5 SI; M = 5.7 CI) Neuropsych testing for descriptive purposes 8

Methods Research Design Double-blind randomized controlled design Participants, evaluator, & coders blind to study condition Trainer (PI) and fidelity checkers not blind to condition 9

Methods Training 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) 10

Independent Variables ( Training Conditions) 11

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Methods Treatment 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. 14

Dependent Variable (Outcome Measure) Pre, Post, and 30-days 15

Methods Psychometrics & 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) 16

Results Questions 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) 17

Results Questions 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 18

ANCOVA Results Significant difference in mean # tasks correct, controlling for pretest level (Total # of tasks = 10) Maintenance 19

Difference Results Fluency ( 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. 20

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) 21

Selected References “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), 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), 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–