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This article was downloaded by:[University of Oregon]On: 9 April 2008Access Details: [subscription number 788774885]Publisher: Psychology PressInforma Ltd Registered in England and Wales Registered Number: 1072954Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
Neuropsychological RehabilitationAn International JournalPublication details, including instructions for authors and subscription information:http://www.informaworld.com/smpp/title~content=t713684225
Evidence-based practice guidelines for instructingindividuals with neurogenic memory impairments: Whathave we learned in the past 20 years?Laurie A. Ehlhardt a; Mckay Moore Sohlberg b; Mary Kennedy c; Carl Coelho d;Mark Ylvisaker e; Lyn Turkstra f; Kathryn Yorkston ga The Teaching Research Institute-Eugene, Western Oregon University, Monmouth,USAb University of Oregon, Eugene, USAc University of Minnesota, Minneapolis, USAd University of Connecticut, Storrs, USAe College of Saint Rose, Albany, New York, USA
f University of Wisconsin, Madison, USAg University of Washington, Seattle, USA
First Published on: 26 February 2008To cite this Article: Ehlhardt, Laurie A., Sohlberg, Mckay Moore, Kennedy, Mary, Coelho, Carl, Ylvisaker, Mark,Turkstra, Lyn and Yorkston, Kathryn (2008) 'Evidence-based practice guidelines for instructing individuals with neurogenicmemory impairments: What have we learned in the past 20 years?', Neuropsychological Rehabilitation, 1To link to this article: DOI: 10.1080/09602010701733190URL: http://dx.doi.org/10.1080/09602010701733190
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Evidence-based practice guidelines for instructing
individuals with neurogenic memory impairments:
What have we learned in the past 20 years?
Laurie A. Ehlhardt1, McKay Moore Sohlberg2, Mary Kennedy3,
Carl Coelho4, Mark Ylvisaker5, Lyn Turkstra6 and,
Kathryn Yorkston7
1The Teaching Research Institute-Eugene, Western Oregon University,
Monmouth, USA; 2University of Oregon, Eugene, USA; 3University of
Minnesota, Minneapolis, USA; 4University of Connecticut, Storrs, USA; 5College
of Saint Rose, Albany, New York, USA; 6University of Wisconsin, Madison, USA;7University of Washington, Seattle, USA
This article examines the instructional research literature pertinent to teaching
procedures or information to individuals with acquired memory impairments
due to brain injury or related conditions. The purpose is to evaluate the avail-
able evidence in order to generate practice guidelines for clinicians working in
the field of cognitive rehabilitation. A systematic review of the instructional lit-
erature from 1986 to 2006 revealed 51 studies meeting search criteria. Studies
were analysed and coded within the following four key domains: Population
Sample, Intervention, Study Design, and Treatment Outcomes. Coding
included 17 characteristics of the population sample; seven intervention par-
ameters; five study design features; and five treatment outcome parameters.
Interventions that were evaluated included systematic instructional techniques
such as method of vanishing cues and errorless learning. The majority of the
Correspondence should be address to McKay Moore Sohlberg, Associate Professor/Communication Disorders and Sciences, 5285 University of Oregon Eugene, OR 97403
USA. E-mail: mckay@uoregon.edu
The authors gratefully acknowledge colleagues who participated in the ANCDS guidelines
peer review process. They also wish to express sincere appreciation to all the first authors
who so generously gave their time to provide edits and ensure that the review accurately
reflected their work. Finally, the authors thank Cathy Thomas and Laura Beck of the Teaching
Research Institute-Eugene and Rik Lemoncello of the University of Oregon for their assistance
in the preparation of this manuscript.
NEUROPSYCHOLOGICAL REHABILITATION
iFirst, 1–43
# 2008 Psychology Press, an imprint of the Taylor & Francis Group, an Informa business
http://www.psypress.com/neurorehab DOI:10.1080/09602010701733190
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studies reported positive outcomes in favour of systematic instruction.
However, issues related to the design and execution of effective instruction
lack clarity and require further study. The interaction between the target learn-
ing objective and the individual learner profile is not well understood. The evi-
dence review concludes with clinical recommendations based on the
instructional literature and a call to clinicians to incorporate these methods
into their practice to maximise patient outcomes.
Keywords: Evidence based practice guidelines; Memory impairment; Cogni-
tive rehabilitation; Instruction; Errorless learning.
INTRODUCTION
This paper is one of a series of publications by the traumatic brain injury
(TBI) Practice Guidelines Subcommittee established by the Academy of
Neurologic Communication Disorders and Sciences (ANCDS). The commit-
tee was charged with generating evidence-based practice guidelines for
cognitive-communication disorders resulting from TBI. This article examines
the instructional research literature pertinent to teaching procedures or infor-
mation to individuals with acquired memory impairments due to TBI or
related conditions. The purpose is to evaluate the available evidence in
order to generate practice guidelines on instructional methods for clinicians
working in the field of cognitive rehabilitation. (See www.ancds.org/practice.html for publications by this and other subcommittees.)
Why do clinicians need practice guidelines on instruction? Instruction is
central to a variety of cognitive intervention approaches. Whether training
the use of compensatory systems or strategies or facilitating learning of facts
or concepts, clinicians are charged with designing and delivering effective
instruction. Unfortunately, most rehabilitation professionals receive little train-
ing in instructional theory and design. In a survey of medical speech-language
pathologists working in clinical settings throughout the United States, only one-
third reported following an evidence-based instructional approach and nearly
half reported tallying data in their heads and making clinical decisions based
on intuition and experience (Lemoncello & Sohlberg, 2005).
Over the past 20 years, there has been mounting evidence that different
instructional techniques can facilitate learning in individuals with memory
impairment due to acquired neurological conditions. Also accumulating is
evidence that neuronal plasticity can occur in response to structured input
(e.g., Gonzalez-Rothi, 2001, 2006; Laatsch, Thulborn, & Krisky, 2004).
Increasing our understanding and implementation of effective methods for
structuring input via instruction and training practices can facilitate experi-
ence-dependent learning in cognitive-linguistic rehabilitation (Ducharme &
Spencer, 2001; Sohlberg, 2006). In addition to improving rehabilitation
2 EHLHARDT ET AL.
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outcomes, there are pragmatic benefits to adhering to evidence-based
instructional practices. In an era of reduced funding for cognitive rehabilita-
tion, well-designed and delivered instruction may be key to facilitating
efficient and enduring positive outcomes (Sohlberg &Mateer, 2001; Ylvisaker,
Hanks, & Johnson-Green, 2003).
Review of findings from previous meta-analyses
Special education possesses an abundant literature evaluating instructional
techniques that is highly relevant to teaching people with acquired cognitive
impairments. Several meta-analyses have attempted to parse out the most
effective instructional practices and components within the special education
literature (Adams & Engelmann, 2006; Kavale & Forness, 2000; Mastropieri,
Scruggs, Bakken, & Whedon, 1996; Swanson, 1999, 2001; Swanson, Carson,
& Sachse-Lee, 1996; Swanson & Hoskyn, 1998). Of particular interest to the
current paper are the series of meta-analyses by Swanson and colleagues
(1996–2001). Following an extensive search yielding over 900 data-based
articles, the authors selected 180 studies that met the inclusion criteria
(e.g., comparison/control group; sufficient data to calculate effect sizes).
These studies were categorised into one of four groups based on the instruc-
tional techniques that were employed. The results indicated that the
Combined Model that used both Direct Instruction and Strategy Instruction
techniques in concert produced the largest effect size. Strategy Instruc-
tion alone, Direct Instruction alone, and Nondirect/Nonstrategy instruction
showed respectively smaller effect sizes. These meta-analyses are part of a
rich experimental literature within the field of special education that supports
the use of explicit instructional techniques to effectively teach individuals
with learning disabilities (Sohlberg, Ehlhardt, & Kennedy, 2005).
Strategy instruction is a specific instructional arena that special education
has carefully evaluated. Graham and Harris (2003) conducted a meta-analysis
supporting the effectiveness of Self-Regulated Strategy Development (execu-
tive function/self-regulation scripts embedded within the curricular delivery)
for a variety of students with and without disability. Similarly, Kim, Vaughn,
Wanzek, and Wei (2004) provide a meta-analysis of graphic organisers used
with a variety of students with and without disability. The burgeoning work in
special education on current practices in strategy instruction has influenced
the brain injury field; however, this is an area that needs further attention.
The current review of instructional practices limits its consideration of specific
strategy instruction due to the lack of research involving the brain injury popu-
lation; clinicians and researchers are encouraged to examine the available
cross-disciplinary evidence. Executive function strategy and problem-
solving interventions specific to the brain injury population are detailed in a
recent practice guidelines manuscript (Kennedy et al., 2008 this issue).
EVIDENCE-BASED PRACTICE GUIDELINES FOR INSTRUCTION 3
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The field of neuropsychology has built upon the special education research
and evaluated instructional design and teaching procedures in the population
of people with acquired neurogenic memory disorders. A meta-analysis eval-
uated the effects of errorless learning and the method of vanishing cues across
11 studies (Kessels & deHaan, 2003). This analysis revealed that error elim-
ination strategies during the learning process produced a moderate effect size
of .59 when compared to trial and error strategies. This analysis also showed
a large effect size (.87) for studies specifically evaluating errorless learning
and a small effect size (.27) for those evaluating the method of vanishing
cues (.27); however, the relatively few studies in the latter category may
have affected these results. Overall, this meta-analysis encourages more
evaluations of the application of errorless learning techniques to real world
settings.
The current report provides a detailed review of the instructional literature
from 1986 to 2006 relevant to the treatment of the neurogenic population with
acquired memory disorders. Because instruction represents a broad interven-
tion domain applied to a wide variety of cognitive interventions, this paper
does not utilise the standard classification system of practice standards,
guidelines, and options (Miller et al., 1999); instead, it describes general
instructional practices based on the research evidence.
METHODS
Writing Committee process
The ANCDS TBI Practice Guidelines Committee was formulated to generate
practice guidelines for working with persons living with the effects of trau-
matic brain injury. The committee initially established a philosophy and
rationale for the purpose and use of evidence-based guidelines (Kennedy
et al., 2002) including identifying factors critical to scientific clinical
decision-making (Ylvisaker et al., 2002). Priorities for domains of practice
guidelines were also established. To date, the committee has reviewed the
literature and generated evidence-based guidelines in the following clinical
domains: use of direct attention training (Sohlberg et al., 2003); use of exter-
nal aids to manage memory impairments (Sohlberg et al., 2007); use of stan-
dardised assessment in traumatic brain injury (Turkstra et al., 2005);
behavioural interventions (Ylvisaker et al., 2007); and executive function
interventions (Kennedy et al., 2008 this issue). Each paper included Tables
of Evidence with agreed upon coding categories that allowed scrutiny and
comparison of research reports. Authors analysed the evidence in order to
develop clinical practice guidelines. Prior to submission, each paper was
sent for external review to the ANCDS membership and to first authors
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whose studies were analysed in the paper. Feedback was incorporated, and the
paper was submitted to the peer review process for the relevant journal. We
followed this protocol for the current guidelines paper. We received a total of
seven peer reviews. First author (and in one case, second author) reviews
were requested from researchers who had authored two or more papers
included in the evidence base, comprising a total of six researchers. All six
review solicitations were accepted and returned with comments, thus ensur-
ing that the interpretation and coding of their studies was accurate.
The goal of this paper is to identify effective instructional practices in cog-
nitive rehabilitation that the research literature supports with a reasonable
degree of certainty. In order to be inclusive in our search and evaluate the
available evidence relevant to populations with functionally equivalent cog-
nitive-linguistic impairments, we made the decision in this paper to include
cross-population studies. Clients with traumatic brain injury, the target popu-
lation of the guidelines subcommittee, represent a complex, heterogeneous
group in which cognitive, communication, and behavioural impairments
interact and are differentially affected by changing environments. Because
memory impairments following TBI are not a uniform condition specific to
this diagnosis, it is important to consider other sources to verify treatment
methods (Ylvisaker et al., 2002). Thus, the authors of this paper reviewed lit-
erature that included the following aetiologies, all of which commonly exhibit
memory and/or learning impairments as a central symptom: acquired brain
injury (TBI plus other neurogenic aetiologies such as cerebral vascular acci-
dents, anoxic events, brain tumour, and neuro-infectious diseases), dementia,
and schizophrenia. These categories were consistent with the breakdown in
the research literature. The decision to group a variety of aetiologies into
an acquired brain injury category was made for two reasons. First, the
review of the literature did not support systematic differences in the outcomes
of intervention. Second, a number of studies evaluated mixed participant
groups, making it difficult to parse out aetiology-specific findings within
the acquired brain injury population. Schizophrenia is not a neurogenic dis-
order; however, there is increasing evidence that this population experiences
difficulties with new learning and memory similar to people with acquired
brain injury (McKenna, Clare, & Baddeley, 1995). Examination of the
instructional literature for this population reinforces a number of instructional
recommendations for people with memory impairments from a broad spec-
trum of aetiologies.
Identifying, gathering, and extracting intervention studies
The following databases were searched for articles published between 1986
and 2006: Academic Search Premier, Education Research Complete, ERIC,
Medline, Psychology and Behavioural Sciences Collection, and PsycINFO.
EVIDENCE-BASED PRACTICE GUIDELINES FOR INSTRUCTION 5
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We restricted our search to the past 20 years since this period included all of
the primary instructional methods investigated with the target populations. Key
combinations of the following terms were used: brain injury, head injury,
head trauma, brain trauma, dementia, schizophrenia, amnesia, memory,
instruction, errorless learning, spaced retrieval, expanded rehearsal, distributed
practice, vanishing cues, trial and error, errorful, discovery learning, standard
anticipation, backward-forward chaining, memory, executive function, dysex-
ecutive, cognitive, computers, computer assisted instruction, and remediation.
The search methods initially yielded 2155 records narrowed to 857 records
for review. Hand searches of extant references (i.e., studies cited within an
article) were also conducted. Abstracts or full articles were then reviewed,
applying agreed upon selection criteria. Studies were included whose partici-
pants had acquired memory impairment as their primary cognitive deficit due
to a variety of aetiologies, including acquired brain injury (ABI) (e.g., TBI,
cerebrovascular accident, encephalitis), dementia (Alzheimer’s or vascular
type), or schizophrenia/schizoaffective disorder. Only studies that evaluated
the application of instruction or training to the learning (or relearning) of
information or procedures were included. Studies also had to provide original
quantitative and/or qualitative (i.e., case study) data. When it was evident
that two different studies (whether published separately or in the same
article) evaluated the same participants, those participants were counted
twice. Studies were excluded that: (1) applied instruction or training pro-
cedures to cognitive impairments other than memory (e.g., use of errorless
learning to treat anomia); (2) reported findings from a study reviewed
earlier using the same participants; or (3) consisted of reviews of other articles
without presenting original data. Forty-eight studies met the above criteria
and were selected for final review. We incorporated three more studies
based on first author reviews for a total of 51 studies.
As part of the ANCDS practice guidelines developed for individuals with
Alzheimer’s dementia, Hopper et al. (2005) conducted a systematic review of
the spaced retrieval literature for this population; hence, those studies were
not included in this review. However, studies evaluating spaced retrieval in
the TBI population were identified and included in this review, as well as
those studies within the dementia population that were not included in the
review by Hopper and colleagues.
Reviewing and coding studies into Tables of Evidence
Tables of evidence were organised by identifying relevant parameters within
the following four key domains: population sample, intervention, study
design, and treatment outcomes. Coding included 17 characteristics of the
population sample; seven intervention parameters; five study design features;
and five treatment outcome parameters (see Table 1 for a summary of the
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TABLE 1
Summary of the number and percentage of studies reporting population
characteristics, intervention parameters, design features, and outcomes
(N ¼ 51)
Number and (percent) of studies reported
Type of evidence
Class I 1 (2)
Class II 6 (12)
Class III 26 (51)
Class IV 15 (29)
Class III & IV 3 (6)
Demographic variables
Number 51 (100)
Age 50 (98)
Male:Female 41 (80)
Aetiology 51 (100)
Site of injury 20 (39)
Time post-onset 39 (76)
Neuropsychological tests 51 (100)
Premorbid IQ 16 (31)
Initial severity 12 (24)
Memory severity 41 (80)
Dual diagnosis/co-morbidity 20 (39)
Selection criteria 29 (57)
Treatment history 9 (18)
Medication 11 (22)
Education 29 (57)
Occupation 19 (37)
Living Situation 28 (55)
Intervention
Instructional approach 51 (100)
Additional components 24 (47)
Treatment targets I ¼ 33 (65) P ¼ 10 (20)
I & P ¼ 8 (17)
Treatment dosage 51 (100)
Treatment setting 25 (49)
Treatment provider 26 (51)
Measurement 51 (100)
Study design
Design 51 (100)
Statistics 41 (80)
Reliability/validity 7 (14)
Outcomes
Ecological validity 14 (27)
Immediate outcomes 100 (100)
Generalisation 22 (43)
Maintenance 30 (59)
I ¼ Information; P ¼ Procedures.
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number and percentage of studies reporting population characteristics,
intervention parameters, design features, and outcomes). The full Tables of
Evidence are presented in three appendices. Appendix A displays the coded
population sample characteristics, Appendix B displays the coded interven-
tion characteristics, and Appendix C displays the coded parameters related
to study design and outcomes. There are three possible types of coding.
Some parameters list the relevant study content; other parameters contain a
“1” indicating the study reported the parameter or a “0” indicating the
study did not report it; and, as described later, intervention outcomes are
coded with þ, /, or – indicating positive, qualified, or negative findings,
respectively. Each appendix groups the three diagnostic categories separately
(ABI—38 studies; dementia—7 studies; and schizophrenia/schizoaffectivedisorder—6 studies) to allow for population-specific analyses. Studies
within each of the three diagnostic groups are ordered chronologically in
the appendices
Clinical practice recommendations must strongly consider the strength of
the research evidence. Therefore, in Appendix C, each study was also rated
according to the revised American Academy of Neurology (AAN) classifi-
cation system (i.e., Class I–IV evidence) (American Academy of Neurology,
2004; www.aan.org). In this system, Class I studies include prospective,
randomised controlled clinical trials with masked outcome assessment in a
representative population with qualifiers. Class II studies are prospective
matched group cohort studies with masked outcome assessment in a represen-
tative population that meet Class I criteria or randomised controlled trials that
lack one criterion for Class I evidence. Class III studies include all other con-
trolled trials where outcome assessment is independent of patient treatment in
a representative population. Class IV is evidence from uncontrolled studies,
such as case reports or expert opinion.
The first author coded all 51 intervention studies. Reliability coding with
the second author was conducted for 26 out of the total of 51 studies (51%)
for all coding categories, except for five parameters: the type of instruction
and four of the outcome components (immediate outcomes, ecological val-
idity, generalisation and maintenance). The second author coded these four
parameters for all 51 studies. There were nine points of disagreement
related to categorising types of instruction (e.g., discriminating between
errorless learning and systematic instructional packages), eight points of dis-
agreement related to determining immediate outcomes (e.g., discriminating
between a “qualified” versus “negative” outcome), one point of disagreement
related to the determination of ecological validity, and no points of disagree-
ment related to generalisation and maintenance outcomes. Inter-rater
reliability for these four parameters averaged 90%, with overall reliability
at 98% for the 26 studies reviewed in their entirety. Disagreements were
easily resolved by discussion, with components re-categorised accordingly.
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RESULTS
Population sample characteristics
This section summarises relevant population sample characteristics across
the three population groups (see Appendix A for details).1
Number of participants, age, gender, aetiology, site of injury,
time post-onset
Acquired brain injury. There were 451 experimental participants with
memory impairment, 42 control participants with cognitive disabilities, and
163 non-disabled control participants across the 38 studies. Ages ranged
from 18 to 78 years, with two studies involving children 8–11 years old.
The experimental participants were predominantly adult males (.2:1). The
aetiology of memory impairment included a wide range of conditions: TBI,
CVA (including anterior and posterior communicating artery haemorrhage),
encephalitis, brain tumour, Korsakoff’s syndrome, anoxia, brain abscess,
Parkinson’s disease, toxicity, encephalopathy, and cerebral infection. Site
of injury and/or imaging findings were reported in 17/38 (45%) of the
studies. Time post-onset (TPO) was reported in 31/38 (82%) of the studies
with the majority of participants at least one year post-onset and others
several years post-onset (e.g., 15 years). Only three studies reported on par-
ticipants with symptom onset of less than one year (Dou, Man, Ou, Sheng,
& Tam, 2006; Glisky & Delaney, 1996; Wilson, Baddeley, Evans, & Shiel,
1994).
Dementia. Across the seven studies, there were 55 experimental partici-
pants and eight non-disabled control participants, ranging in age from 65
to 89 years. The participants were predominantly male, with Alzheimer’s
dementia as the most common aetiology, followed by vascular dementia.
Imaging findings were reported in 3/7 (43%) of the studies (Clare et al.,
2002; Haslam et al., 2006; Winter & Hunkin, 1999). Symptom onset date was
reported in 2/7 (29%) of the studies, and ranged from 18 months to 5 years
prior to the study (Clare et al., 2000; Haslam, Gilroy, Black, & Beesley, 2006).
Schizophrenia/schizoaffective disorder. Across the six studies, therewere
203 participants with schizophrenia/schizoaffective disorder and memory
impairment, 21 control participants with schizophrenia/schizoaffective
1To limit manuscript space devoted to citations in the results section, the first two authors
selected and cited the two most representative studies to illustrate certain evidence parameters.
For objective evidence parameters (e.g., demographics) with more than three studies, percen-
tages were reported without citations.
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disorder without memory impairment, and 88 non-disabled control
participants. The experimental participants were predominantly male, and
ages ranged from 18 to 55 years, with the majority of participants in the
30–40 year age range. Site of injury/imaging findings were not reported for
this population. Symptom onset date was determined by the date of first
hospitalisation relative to the start of the study, which ranged from 1 month
to 34.7 years prior.
Neuropsychological testing, premorbid IQ, initial severity, memory
severity, dual-diagnosis/co-morbidity, selection criteria
Acquired brain injury. Neuropsychological test data were available in all
38 studies; however, the type and number of measures used varied consider-
ably. Premorbid IQ was reported in 10/38 (26%) of the studies. Initial sever-
ity (length of coma and/or post-traumatic amnesia) was reported in 12/38(32%) of the studies and was not relevant to participants in several studies
given the aetiology (e.g., Korsakoff’s syndrome). Severity of memory impair-
ment was reported in 33/38 (87%) of the studies. Of these, 18/33 (55%)
reported the levelof impairment as “severe”, “profound”, “marked”, “significant”,
or “chronic, affecting everyday memory”. Ten out of 33 (30%) of the studies
included participants with a range of severity levels: “mild”, “moderate”, and
“severe”, while in other studies, severity was implied on the basis of cut-off
scores. Few studies clearly linked performance on standardised memory
assessments and screening tools to the described levels of memory impair-
ment (e.g., Page, Wilson, Shiel, Carter, & Norris, 2006; Tailby & Haslam,
2003). In addition, few studies described the specific type of memory impair-
ment. Descriptors reported typically included “anterograde” or “episodic”
memory impairments (e.g., Andrewes & Gielewski, 1999; Komatsu,
Mimura, Kato, Wakamatsu, & Kashima, 2000).
Dual-diagnosis/co-morbidity data were reported in 17/38 (45%) of the
studies. In addition to the memory impairments described above, other cog-
nitive impairments reported included: executive function and attention
impairments; disorientation; anomia and other language impairments; visuo-
perceptual disorders; motor speech impairments or motor slowing; diabetes;
and/or seizures (e.g., Glang, Singer, Cooley, & Tish, 1992; Glisky, Schacter,
& Tulving, 1986a, 1986b). For several of the remaining studies, participants
were excluded on the basis of a dual-diagnosis or co-morbidity. (Note: As so
few studies reported on vision, hearing, and motor status, these data were
included in this category when available.) Selection criteria were reported
in 16/38 (42%) studies.
Dementia. Neuropsychological test data were available across all seven
studies. Premorbid IQ was reported in 6/7 studies (86%). Two of the seven
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studies included only participants with minimal or mild dementia (Clare,
Roth, Wilson, Carter, & Hodges, 2002; Clare et al., 2000), while the remain-
ing studies included those with mixed severities or moderate–severe demen-
tia only (e.g., Metzler-Baddeley & Snowden, 2005; Ruis & Kessels, 2005).
Six of the seven studies (86%) described severity of memory impairment
with participants having “significant”, “severe”, or “profound” memory
impairments. Dual-diagnosis/co-morbidity data were provided in 3/7(43%) studies (Haslam et al., 2006; Metzler-Baddeley & Snowden, 2005;
Winter & Hunkin, 1999). In addition to memory impairment, other cognitive
impairments included general decline in intellectual ability, impaired concen-
tration, disorientation, and word-finding difficulties (Haslam et al., 2006;
Metzler-Baddeley & Snowden, 2005; Winter & Hunkin, 1999). Selection cri-
teria were reported in 6/7 (86%) studies.
Schizophrenia/schizoaffective disorder. Neuropsychological testing was
completed in all six studies; however, the number of measures used was often
limited, thus precluding detailed descriptions of participant profiles. Premorbid
IQ was not reported for this population group. Severity of memory impair-
ment was reported in only two (33%) of the studies and determined via
cut-off scores (Kern et al., 2005; O’Carroll, Russell, Lawrie, & Johnstone,
1999). Selection criteria were reported in 6/6 (100%) studies.
Treatment history, medication status, education, occupation, living
situation
Acquired brain injury. Treatment history was reported in 9/38 (24%) of
the studies. Medication status was rarely reported – 2/38 (1%) studies
(Andrewes & Gielewski, 1999; Parkin, Hunkin, & Squires, 1998). Education
levels were reported in 21/38 (55%) of the studies with the majority of the
adult participants completing high school education, and many achieving
some level of post-secondary education as well. Occupational history was
available in 13/38 (34%) of the studies, and included reports of participant
employment post-intervention (e.g., Andrewes & Gielewski, 1999; Hillary
et al., 2003). Post-injury living situation was reported in 18/38 (47%)
studies, and included home/community dwelling, assisted living centres,
and long-term care residence.
Dementia. Treatment history was not reported. Medication status was
reported in 3/7 studies (43%) (Clare et al., 2002; Dunn & Clare, 2007;
Metzler-Baddeley & Snowden, 2005). Education status was reported in 2/7(29%) studies (Haslam et al., 2006; Ruis & Kessels, 2005), with participants
having completed up to 10 years of education. Occupational history was
reported in 4/7 (57%) studies, with participants having worked in a variety
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of jobs (e.g., business owners, clerical, engineers) prior to their retirement.
Living situation was reported in 6/7 (86%) studies, with the majority of par-
ticipants living with a family member.
Schizophrenia/schizoaffective disorder. Treatment history was not
reported. Medication status was reported in all six studies and included
anti-psychotic and neuroleptic medications. Education levels in all six
studies were reported, with the majority of participants completing at least
high school education. Occupational history was reported in only 1/6(17%) studies (Kern, Liberman, Kopelowicz, Mintz, & Green, 2002).
Living status was not consistently reported but was implied on the basis of
the described treatment setting (e.g., in-patient hospital setting; outpatient
clinic, community dwelling).
To summarise, the description of population characteristics varied widely
within and between the three population groups. The majority of the studies
provided sufficient information to develop a basic profile of study partici-
pants; however, there were notable gaps in the literature. For example,
while the majority of the studies included neuropsychological testing, clear
linkages between assessment data and the determination of both the type
and severity of memory impairment were limited. This trend in combination
with the relative lack of information in other domains such as treatment
history and medication status limit the extent to which results can be gener-
alised to individuals beyond those involved in the studies (i.e., external
validity).
Intervention
This section summarises the types of instructional methodologies, additional
training components, treatment targets, dosage, treatment settings and provi-
ders, as well as outcome measurements across the 51 studies (see Appendix B
for details).
Instructional methods
Two broad instructional categories emerged from the review: (1) systema-
tic instructional methods (e.g., method of vanishing cues, errorless learning,
and spaced retrieval); and (2) conventional methods (e.g., errorful learning/trial and error learning). The primary goal of errorless learning is to eliminate
errors during the acquisition phase of learning by providing models before
a client attempts a response; guessing is discouraged (Baddeley & Wilson,
1994). The method of vanishing cues (MVC) is a form of chaining that
provides the client with progressively stronger or weaker cues following
recall attempts of the targeted information/procedures (Glisky, Schacter, &Tulving, 1986a, b). Spaced retrieval (i.e., expanded rehearsal) is a form of
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distributed practice that provides individuals with severe memory impairment
practice at successfully recalling information over expanded time intervals
(Melton & Bourgeois, 2005). Spaced retrieval incorporates errorless learning
but follows a prescribed practice regimen. In general, these systematic
instructional methods emphasise explicit, carefully faded models/prompts.
The conventional methods (i.e., trial-and-error learning, errorful learning,
standard anticipation) emphasise recall of the targeted information or skill
without prior models/prompts, with the trainer providing the models only
following errors.
Studies were grouped into the following six intervention categories and
comparison conditions:
1. Errorless learning (EL). The study evaluated errorless learning with no
comparison condition or group.
2. Errorless learning versus errorful learning (EL vs. EF). The study
compared EL vs. EF, a comparison group and/or an earlier EL training
protocol.
3. Method of vanishing cues (MVC). The study evaluated MVC with no
comparison condition or group.
4. Method of vanishing cues versus errorful or errorless learning (EF/EL). The study compared MVC with a comparison condition, such as
errorful learning or errorless learning.
5. Spaced retrieval/spaced presentations (SR). The study primarily eval-
uated spaced retrieval or spaced presentation of information.
6. Systematic instructional packages. The study evaluated a combination
of systematic techniques integrated into an instructional package and/or used a staged-learning process (e.g., Phase 1 ¼ acquisition phase,
Phase 2 ¼ application phase) with or without a comparison con-
dition/group.
The target systematic instructional methodologies varied across the three
aetiology groups as described in the following section.
Acquired brain injury. The target systematic instructional methodologies
varied for the ABI group, with comparisons of EL versus EF and systematic
instructional packages as the predominant methods (11 and 13 studies,
respectively); one study evaluated EL without a comparison condition/group (Parkin et al., 1998). There were five studies evaluating MVC with
no comparison and five with a comparison, while three studies focused
primarily on spaced retrieval/spaced presentations.
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Dementia. Three studies compared EL versus EF (Haslam et al., 2006;
Metzler-Baddeley & Snowden, 2005; Ruis & Kessels, 2005), three evaluated
systematic instructional packages (Clare et al., 2000, 2002; Dunn & Clare,
2007), and one study evaluated EL alone (Winter & Hunkin, 1999).
Schizophrenia/schizoaffective disorder. Five studies compared EL
versus EF, while one study evaluated two different systematic instructional
packages with a control group (Young et al., 2002).
Across groups, documentation of specific training procedures for each
instructional methodology varied. Several studies provided sufficient detail to
allow for replication (e.g., Andrewes & Gielewski, 1999; Glisky & Schacter,
1989; Hunkin, Squires, Aldrich, & Parkin, 1998).
Additional instructional components
Several studies emphasised instructional components the researchers
hypothesised would increase the participants’ active processing of the
targeted information/procedures, while keeping errors to a minimum.
These components took the form of either a strategy (e.g., verbal elaboration,
imagery, prediction-reflection, evaluative questioning/self-generation of
responses) or an emphasis on stimulus manipulation (e.g., varied training
examples for the targeted information/task step or stimulus pre-exposure).
Acquired brain injury. Eight studies included a strategy component (e.g.,
Evans et al., 2000; Tailby & Haslam, 2003), while 12 studies emphasised
stimulus manipulation (e.g., Glisky & Schacter, 1987; Stark, Stark, &
Gordon, 2005).
Dementia. Almost half of the studies (3/7) included a strategy com-
ponent (Clare et al., 2000, 2002; Metzler-Baddeley & Snowden, 2005),
while none of the studies explicitly described stimulus manipulation.
Schizophrenia/schizoaffective disorder. One out of the six studies (17%)
emphasised strategy instruction (Young, Zakzanis, Campbell, Freyslinger, &
Meichenbaum, 2002), while four of the studies described stimulus manipu-
lation (e.g., Kern et al., 2002, 2005).
Instructional targets
Instructional targets were grouped into two categories: information and
procedures. Information targets included: word lists, face–name associations,
facts, object names, definitions, concepts, and curricula content (e.g., maths,
reading). Procedures included a variety of multi-step tasks, such as: index
card filing, word processing, data entry, programming electronic aids,
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external memory aid use, and route finding. Familiarity of the instructional
targets varied with both unfamiliar and/or familiar information and pro-
cedures trained across the three population groups.
Acquired brain injury. Most of the studies (24/38; 63%) focused on
training information, while 7/38 (18%) targeted procedures, and 7/38(18%) targeted both.
Dementia. The majority of the studies (6/7; 86%) targeted information
while one study (Clare et al., 2000) evaluated instruction that targeted both
information and procedures.
Schizophrenia/schizoaffective disorder. Half of the studies (3/6) tar-
geted information and the other half taught procedures.
Treatment dosage
Treatment dosage refers to the frequency of the treatment sessions and the
duration of treatment, both in terms of length of session and the total amount
of time participants received treatment.
Acquired brain injury. Treatment frequency ranged from one session
only to daily sessions. Treatment duration was also quite varied, with sessions
lasting a minimum of 30 minutes up to 2 hours with total duration, when
specified, from one week up to several months.
Dementia. Treatment frequency ranged from a minimum of one training
session in each condition (2 total) up to 16 sessions. Total duration, when
reported, ranged from one week up to four weeks.
Schizophrenia/schizoaffective disorder. Treatment frequency ranged
from one session only up to six sessions, with durations up to four weeks.
Treatment settings and providers
Treatment settings and treatment providers were not consistently reported
across the three population groups (49% and 53%, respectively).
Acquired brain injury. Half of the studies (19/38) reported treatment
settings. These studies described a range of settings, including laboratory or
clinic settings, work-sites, and home-based treatment delivered via phone
(Melton & Bourgeois, 2005). Treatment providers were reported in 20/38(53%) of the studies and included experimenters and family members, as
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well as computer-delivered stimuli, common to the studies by Glisky and
colleagues (e.g., 1986–1995).
Dementia. Treatment settings and providers were reported in 1/7 (14%)
of the studies (Metzler-Baddeley & Snowden, 2005) that described a combi-
nation of clinic and home-based therapy delivered by both the experimenter
and spouses.
Schizophrenia/schizoaffective disorder. Treatment settings and provi-
ders were reported in 5/6 (83%) of the studies, with the majority conducted
in hospital or clinic settings. Experimenters, supervisors and assistants
provided the treatment.
Measurement
Different types of intervention outcome measurements were used across
the three population groups, with the majority of studies incorporating
more than one type. The most frequently used measure was the number,
percentage, or proportion of targets correctly recalled. A total of 39/51(77%) of the entire sample included this form of measurement with the
population-specific breakdown as follows:
. Acquired brain injury: 28/38 (74%).
. Dementia: 7/7 (100%).
. Schizophrenia/schizoaffective disorder: 3/6 (50%).
Other outcome measures used across the three groups included documen-
tation of error responses or intrusions (e.g., Glisky & Schacter, 1987;
Komatsu et al., 2000; Leng et al., 1991), task completion times (e.g., Glisky,
1995; Glisky & Schacter, 1987; Leng, Copello, & Sayegh, 1991), levels of
independence (Andrewes&Gielewski, 1999), number of trials/sessions to cri-terion (e.g., Ehlhardt, Sohlbert, Glang, & Albin, 2005; Glisky & Schacter,
1988; Turkstra & Bourgeois, 2005), behavioural checklists/questionnaires(e.g., Hunkin, Squires, Aldrich, & Parkin, 1998; Ownsworth & McFarland,
1999; Squires, Hunkin, & Parkin, 1996) and standardised assessments (e.g.,
Dou et al., 2006; Schmitter-Edgecombe, Fahy, Whelan, & Long, 1995;
Winter & Hunkin, 1999). Qualifiers to these measurement systems frequently
included whether the measure was implemented immediately following train-
ing or after a delay, whether recall was free or cued, and whether a recognition
task was also included. These qualifiers were particularly relevant to those
studies in which the determination of the different memory systems (e.g.,
implicit versus explicit memory) underlying performance outcomes was of
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primary interest (e.g., Hunkin, Squires, Parkin, & Tidy, 1998; Tailby &
Haslam, 2003). It was generally unclear whether or not evaluators were
naı̈ve to the training conditions when measuring outcomes; hence, for the
majority of the studies, it was assumed that the trainer also served as the
evaluator.
To summarise, the systematic instructional methods evaluated within and
between aetiology groups varied, the majority of the studies targeting error-
less learning or systematic instructional packages. The studies also varied in
the extent to which the treatment procedures and dosages were sufficiently
detailed to allow a naı̈ve trainer to replicate the treatment, which is important
for establishing external validity. Treatment targets spanned a range of infor-
mation and procedures. A number of studies evaluated word recall, whereas
others selected functional targets, such as: face–name recall, computer task
completion, and external memory aid use. The most common outcome
measure was the number-percentage-proportion of targets correct while
other measures were specifically tailored to the treatment target (e.g., task
completion time for multi-step procedures). Lack of explicit information con-
cerning the evaluators’ knowledge of training conditions limits assessment of
internal validity. Design factors influencing internal validity will be discussed
in the next section.
Study design
This section summarises the classes of evidence, research design, statistics,
reliability-validity, and ecological validity (see Appendix C for details).
Classes of evidence
As previously stated, each study was rated according to the revised
AAN classification system (i.e., Class I–IV evidence) (American Academy
of Neurology, 2004) across population groups as follows. Table 2 shows
classification of research evidence across the three population groups.
Design, statistics, reliability-validity, ecological validity
This section summarises the methodological variables coded, including:
research design and experimental control conditions, statistics, reliability-
validity, and ecological validity. These components are analysed separately
for each population group. For this review, the authors determined that eco-
logical validity had been established when the intervention targets would be
of direct benefit to the study participants in their daily lives (e.g., teaching the
use of an external memory aid or a vocational task the person would poten-
tially utilise).
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Acquired brain injury. Twenty-six of the 38 studies (68%) incorporated
experimental control conditions. There were three between-groups designs
with random assignment. Experimental comparison conditions included:
baseline comparisons (Ownsworth & McFarland, 1999), memory notebook
training versus support group intervention (Schmitter-Edgecombe et al.,
1995), and computer versus therapist-delivered treatment versus control
group (Dou et al., 2006). There were 12 within-subject experimental
studies. Comparison conditions included EL versus EF (e.g., Baddeley &
Wilson, 1994; Evans et al., 2000), EL versus MVC or different treatment
or presentation conditions (e.g., Glisky et al., 1986a; Komatsu et al.,
2000), and baseline comparisons (Ehlhardt et al., 2005). Eight studies
used combinations of both between and within-subject designs with com-
parison conditions similar to the above. Several studies reported counter-
balanced treatment conditions and stimuli as appropriate to the design.
Three studies used combinations of between and/or within-subject
designs and case studies (Glang et al., 1992; Glisky & Delaney, 1996;
Squires et al., 1996). Twelve studies did not use experimental control
and included case studies with and without pre–post treatment
comparisons.
TABLE 2
Classification of research evidence
Number (percent)
Acquired brain injury
(N ¼ 38) Class I 0/38 (0)
Class II 1/38 (3)
Class III 21/38 (55)
Class IV 14/38 (37)
Combinations 2/38 (5)
Dementia
(N ¼ 7) Class I 0/7 (0)
Class II 0/7 (0)
Class III 5/7 (71)
Class IV 1/7 (14)
Combinations 1/7 (14)
Schizophrenia/schizoaffective disorder
(N ¼ 6) Class I 1/6 (17)
Class II 5/6 (83)
Class III 0/6 (0)
Class IV 0/6 (0)
Combinations 0/6 (0)
“Combination” refers to those studies that included various combinations of
Class I–IV designs.
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Levels of statistical significance were reported in 29/38 (76%) studies with
procedures including t-tests, ANOVAs, general linear model analyses, as well
as non-parametric procedures. Statistics were not appropriate for selected
within-subject studies that used visual analysis to determine effectiveness
(e.g., Ehlhardt et al., 2005; Glang et al., 1992). Only four (11%) of the
studies reported reliability and/or validity data related to measures (e.g.,
Ehlhardt et al., 2005; Melton & Bourgeois, 2005). Ecological validity was
considered established in 12/38 (32%) of the studies (e.g., Andrewes &
Gielewski, 1999; Glisky & Schacter, 1987).
Dementia. Four of the seven studies used within-subject designs that
included comparisons of EL vs. EF (Clare et al., 2000; Metzler-Baddeley &
Snowden, 2005; Ruis & Kessels, 2005) and use of a control set of stimulus
items (Clare et al., 2002). Haslam and colleagues (2006) used both
between and within-subjects comparisons when evaluating EL vs. EF and
control group performance. Clare and colleagues (2000) used a combination
of experimental, within-subjects (stable baseline as control), and a case study
design. Winter and Hunkin (1999) used a non-experimental, pre–post com-
parison study of EL. Levels of statistical significance were reported in 5/6(83%) of the studies and included t-tests, ANOVAs, correlational analyses,
and time-series analyses. Reliability and validity were not reported in any
of the studies. Ecological validity was established in 1/7 (14%) of studies
(Clare et al., 2000), in which participants demonstrated improved face–
name recall and use of memory strategies in naturalistic settings.
Schizophrenia/schizoaffective disorder. Three of the six studies (50%)
used between-group experimental designs comparing EL vs. EF, with and
without a control group, and EL vs. symptom management (Kern et al.,
1996, 2002, 2005). The three other studies used between and within-subjects
comparisons (O’Carroll et al., 1999; Pope & Kern, 2006; Young et al., 2002).
Young and colleagues (2002) compared two forms of systematic instruction:
scaffolded instruction versus direct instruction, and included a control group.
Four of the six studies (67%) used randomised assignment (Kern et al., 1996–
2005; Young et al., 2002). Levels of statistical significance were reported in
all of the studies and included t-tests, ANOVA, MANOVA, correlational pro-
cedures and non-parametric tests. Reliability and validity were reported in 3/6 (50%) of the studies (Kern et al., 2005; Kern et al., 2002; Young et al., 2002)
with one study including fidelity of implementation data (Kern et al., 2005).
Ecological validity was incorporated in one of the six studies (social problem
solving—Kern et al., 2005).
To summarise, the research designs used across the three aetiology groups
included between-group and within-subject designs. These different study
designs vary in the extent to which they establish external and internal
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validity. Notably, few studies documented reliability and validity procedures,
limiting the extent to which changes in the dependent variables could be con-
fidently linked to the targeted intervention (i.e., internal validity). Specific
outcomes associated with the targeted interventions are reviewed in the
next section.
Treatment outcomes
This section summarises immediate outcomes and generalisation and main-
tenance of results (see Appendix C for details).
We identified three different categories of immediate outcomes that
described the research results reported in the literature. The immediate out-
comes were coded as favourable (designated by the þ symbol in Appendix
C evidence table) if the instructional method evaluated in the study was
reported to produce positive learning in the dependent variables and/or sig-nificantly stronger learning than a control instructional condition. Outcomes
were coded as qualified (designated by the/symbol) if the instructional
method was reported to produce variable learning on the dependent measures.
Outcomes were coded as negative (using the – symbol) if the target instruc-
tional method was found to produce limited or no advantage to learning in the
dependent variables.2
Several studies, particularly those published in the 1980s and early 1990s,
focused on the basic question of whether or not a particular systematic
instructional method worked and/or resulted in better performance than
another method (e.g., MVC – Glisky et al., 1986; EL vs. EF – Baddeley &
Wilson, 1994). A trend in later studies emphasised the evaluation of enhance-
ments to previously validated methods (e.g., EL with pre-exposure – Kalla,
Downes, & van den Broeck, 2001; EL with self-generated responses – Tailby
&Haslam, 2003). Accordingly, the outcomes of these later studies were coded
by whether or not the established instructional method was again shown to be
effective as well as by the effectiveness of the hypothesised enhancement.
Immediate outcomes
The outcomes are analysed across the three population groups in order to
evaluate global trends. A broad analysis of the aggregate immediate outcomes
revealed solid evidence supporting the use of systematic instructional tech-
niques. A total of 41 out of 51 (80%) studies reported favourable learning
2Outcome decisions were based on statistically-analysed group data, individual participant
data, or both depending on each study’s research design and primary mode of analysis. The
authors acknowledge that for studies with group data only, individual variations in performance
masked by statistical analysis might have resulted in a different outcome assessment had
individual data also been available.
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outcomes using the instructional methods of errorless learning, method of
vanishing cues, spaced retrieval, or systematic instructional packages.
Favourable outcomes occurred in each population group with the least
robust outcomes for the dementia population. In the ABI group, 34 out of
38 (89%) studies reported favourable immediate outcomes, four reported
qualified outcomes, and one study that included children reported negative
outcomes (Landis et al., 2006). Glang and colleagues (1992) also included
children, but reported positive findings. The two studies differed considerably
in terms of number of participants, severity levels, systematic instructional
method (errorless learning or systematic instructional package, respectively),
and study design. In the dementia group, two out of seven studies (29%)
reported favourable immediate outcomes (Clare et al., 2000; Winter &
Hunkin, 1999), while four studies reported qualified outcomes and one
study a negative outcome (Dunn & Clare, 2007). With the exception of
Kern et al. (2002) who reported qualified findings, five out of the six (83%)
studies with participants who have schizophrenia reported favourable
immediate outcomes (e.g., Kern et al., 2005; Pope & Kern, 2006).
Studies varied by type of instruction and outcome measures used to docu-
ment treatment effects. The two studies evaluating EL only reported favour-
able outcomes (Parkin et al., 1998; Winter & Hunkin, 1999). In the 20 studies
comparing EL with EF and/or a control group, 14 (56%) reported favourable
outcomes (e.g., Squires, Hunkin,&Parkin, 1997;Van der Linden,Meulemans,
& Lorrain, 1994; Young et al., 2002), with five studies reporting qualified
findings (e.g., Evans et al., 2000; Metzler-Baddeley & Snowden, 2005;
O’Carroll et al., 1999) and one study reporting negative outcomes (Landis
et al., 2006). All five studies evaluating MVC only reported favourable out-
comes (e.g., Baddeley & Wilson, 1994; Glisky & Schacter, 1988; Glisky
et al., 1986b). In the studies that compared MVC to another instructional con-
dition, three out of five reported favourable findings (Glisky et al., 1986a;
Leng et al., 1991; Riley, Sotirious, & Jaspal, 2004) and two reported qualified
findings (Hunkin & Parkin, 1995; Thoene & Glisky, 1995). All three studies
evaluating spaced retrieval/spaced presentations reported favourable outcomes
(Hillary et al., 2003; Melton & Bourgeois, 2005; Turkstra & Bourgeois, 2005).
The majority of the studies (16/17; 94%) evaluating systematic instructional
packages reported favourable outcomes (e.g., Andrewes & Gielewski, 1999;
Schmitter-Edgecombe et al., 1995; Winter & Hunkin, 1999).
Generalisation
Generalisation outcomes were coded for those studies that evaluated trans-
fer of training to non-trained targets and/or to natural settings. Studies were
coded as positive (þ) if any degree of generalisation was reported and coded
as negative (–) if generalisation was measured but not achieved.
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Acquired brain injury. Generalisation measures were taken in 19 out of
38 (50%) treatment studies. Of those studies, 15/19 (79%) reported partial
or 100% generalisation of treatment targets. For example, in the study by
Ehlhardt and colleagues (2005), generalisation for learning the e-mail pro-
cedures was reported when participants were able to utilise a slightly more
complex e-mail interface. Other studies reported generalisation from labora-
tory to naturalistic settings, while in some cases training in the natural
environment also facilitated generalisation (e.g., Andrewes & Gielewski,
1999; Glisky & Schacter, 1987).
Dementia. Generalisation was reported in one of the seven studies. Clare
and colleagues (2000) reported generalisation of face–name recall to a natur-
alistic setting for two of the six participants and use of memory strategies in
new situations for one participant.
Schizophrenia/schizoaffective disorder. Generalisation measures were
taken in two of the six studies (33%). Kern and colleagues (2005) reported
that the experimental group generalised trained social problem-solving
skills to novel problem-solving scenarios. Young and colleagues (2002)
noted that the scaffolded instruction group demonstrated significant improve-
ment on selected generalisation assessment measures (e.g., object sorting
task).
Maintenance
Maintenance outcomes were coded when re-assessment of trained targets
occurred more than one day following the cessation of training since that was
the minimum time reported by authors as “maintenance”.
Acquired brain injury. Maintenance checks were reported in 24 out of
38 (63%) of the studies. All 24 studies reported partial or 100% maintenance
of treatment targets from a few days to nine months post-intervention
(e.g., Andrewes & Gielewski, 1999; Thoene & Glisky, 1995).
Dementia. Maintenance checks were reported in two of the seven studies
(Clare et al., 2002, 2000) and revealed generally positive findings with reten-
tion of therapy gains up to six months post-intervention.
Schizophrenia/schizoaffective disorder. Maintenance checks were
reported in four out of six (67%) studies. Results were mixed. Kern and col-
leagues (2002) reported a decline in the performance of work-related tasks
across both the intervention groups at three months, while Kern and colleagues
(2005) reported maintenance of social problem-solving skills at three months.
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One notable difference between the studies was that the Kern et al. (2002)
supplied two, 45–60 minute sessions and no opportunity to practise skills
post-training, whereas Kern and colleagues (2005) supplied six hours of train-
ing over two days with the opportunity to practice skills post-training.
To summarise, these results suggest that systematic instructional
approaches can produce durable/flexible acquisition of skills and infor-
mation. Further, the results of those studies measuring generalisation under-
score the importance of incorporating specific training components that
support “firm” skill and knowledge acquisition, maintenance, and generalis-
ation to “real-life”, personally meaningful contexts.
DISCUSSION
Globally, the research evidence provides strong support for the effectiveness
of systematic instruction. However, it is the details surrounding the design
and execution of that instruction that lack clarity and require further study.
Learning is complex, and the interaction between the target learning objective
and the individual learner profile is not well understood. While this review
demonstrates that systematic instructional techniques are helpful for individ-
uals with acquired memory impairments, identifying the most effective com-
bination of variables pertaining to the training procedures, the treatment task,
and participant characteristics requires dynamic assessment with each client.
The research does, however, suggest several themes, or practice guidelines
that can assist clinicians in designing, evaluating, and modifying their instruc-
tion based on client performance.
Key training variables
Specificity of training. A dominant theme in the research is the need to
reduce hyper-specificity of training conditions and increase effortful proces-
sing in order to facilitate flexible learning and generalisation. Stimulus var-
iance helps to reduce hyper-specificity. Strategy components (e.g., verbal
elaboration) encourage effortful processing, which can lead to improved
attention, encoding, and organisation during acquisition as well as facilitate
explicit retrieval (Riley & Heaton, 2000; Riley et al., 2004). However,
these components also run the risk of increasing recall errors. Maintaining
a balance between constraining errors and encouraging effortful processing
is thus critical to careful treatment planning (e.g., Komatsu et al., 2000;
Tailby & Haslam, 2003).
Strategies. Studies were coded as having a “stimulus variation” com-
ponent if there was an emphasis on training multiple exemplars (e.g.,
Glisky & Schacter, 1987; Stark et al., 2005) or the stimulus was enhanced
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in some other way (stimulus pre-exposure; Kalla et al., 2001). Studies were
coded as having a “strategy component” if the intervention included tech-
niques such as verbal elaboration, imagery, or self-generated responses
(e.g., Clare et al., 2000; Tailby & Haslam, 2003). At least 16 of the 51
studies emphasised stimulus variability, with 15/16 (94%) of these reporting
positive findings. Of the 51 total studies, 12 included a strategy component.
Of these, 9/12 (75%) reported positive findings, while three reported quali-
fied outcomes. Interestingly, two of these latter studies (Evans et al., 2000;
Thoene & Glisky, 1995) cited the use of imagery and/or verbal elaborationas contributing to better recall. Both of these are considered to contribute
to more effortful processing compared to using EL or MVC alone.
Practice. Another critical training variable is providing sufficient prac-
tice. There was a clear trend in this literature review suggesting that more
practice leads to more durable learning. For example, 14 of the 16 studies
targeting multi-step procedures (e.g., data entry, external memory aid use)
reported favourable treatment outcomes and all but one prescribed high treat-
ment dosages, ranging from at least six to 30 sessions or more (e.g., Andrewes
& Gielewski, 1999; Hunkin, Squires, Aldrich & Parkin, 1998). The two
studies that that did not report clear positive results held less than four total
training sessions (Evans et al., 2000; Kern et al., 2002).
Spacing or distribution of practice trials (i.e., spaced retrieval/expandedrehearsal) is another key training variable, a finding well supported in the
literature for non-disabled individuals (Donovan & Radosevich, 1999) and
for those with memory impairment due to dementia (Hopper et al., 2005).
Hopper and colleagues reviewed 15 studies in which all participants learned
some or all of the target information taught using spaced retrieval. In the
current review, three studies targeted spaced retrieval or spaced presentations
for individuals with TBI, all of which reported favourable outcomes (Hillary
et al., 2003; Melton & Bourgeois, 2005; Turkstra & Bourgeois, 2005). Further,
several other studies in this review that included spaced retrieval/distributedpractice as part of their errorless learning or systematic instructional
package also reported favourable outcomes (e.g., Clare et al., 2000; Ehlhardt
et al., 2005).
Both the frequency and distribution of practice trials contribute to mastering
targeted skills and information, which is essential if one is to use the skills/information in daily life. A “criterion for mastery” is the a priori determination
of the level of performance (e.g., accuracy, level of independence, time frame)
indicative of such mastery. For example, a clinician and client might determine
that mastery has been reached when a data entry task can be performed with
100% accuracy for three consecutive sessions. In this review, the majority of
the studies did not establish a criterion for mastery since the primary research
questions were concerned with whether a particular instructional method
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worked and/or if it was significantly better than another method. In other
words, information/skill mastery was not always the primary goal. That
said, 13 of the 51 studies (25%) included a criterion for mastery. The majority
of these studies 11/13 (85%) reported positive outcomes, several of which
included high treatment dosages and distribution of practice trials as described
above (e.g., Ehlhardt et al., 2005; Glisky & Schacter, 1989).
Task characteristics. A number of the studies remind us of the importance
of considering task characteristics when designing intervention. For example,
multiple studies by Glisky and her colleagues (1986–1989) evaluating the
method of vanishing cues suggested that complex procedures can be learned
if they are broken into simple components, and if the knowledge relevant to
carrying out the procedures is explicitly trained. Evans and colleagues
(2000) conducted nine experiments in three study phases to compare errorless
to errorful learning. Their results suggested that tasks and recall conditions that
facilitated retrieval of implicit memory for learned material (e.g., learning
names given a first letter cue) benefit from errorless learning methods, while
those that require explicit recall of novel associations (e.g., learning a route
or programming a device) do not benefit from errorless learning.3 Similarly,
Thoene and Glisky (1995) showed a differential response to MVC based on
the type of task. They suggested that MVC was not beneficial for learning arbi-
trary associations, whereas more explicit, mnemonic techniques were shown to
be more beneficial for such material.
Ecological validity. Of most interest to clinicians is the evidence support-
ing the learning of ecological tasks. As previously stated, we defined instruc-
tional targets as being ecologically valid if the target constituted information
or skills that the study participants would use in their own daily lives. Of the
51 studies, 14 (27%) utilised ecologically valid tasks. Targets ranged from
face–name associations to recall of relevant people, training the use of exter-
nal memory aids or computer tasks, as well as academic skills. Of these
studies, 100% reported positive findings. This high percentage of positive
outcomes supports Bradely, Kapur, and Evan’s (2003) assertion that task vari-
ables, such as motivational and emotional significance, help memories to last.
Specifically, the evidence suggests learning may be facilitated when tasks or
information are inherently functional to an individual. Another interesting
trend noted in this subset of ecologically valid studies was that all reported
high treatment dosages (with a minimum of six treatment sessions), and all
incorporated task analyses to train procedures and/or were explicit in identi-
fying the target learning objective for the participant.
3Other authors would argue such procedural tasks rely on implicit rather than explicit
memory (e.g., Baddeley & Wilson, 1994; Page et al., 2006).
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Key participant variables
No clear relationships between aetiology of memory impairment and
responsiveness to instructional methods were observed in this cross-
population analysis. At this point, we can say that individuals with memory
impairment from a variety of causes have been shown to benefit from sys-
tematic instruction, suggesting that it may be fruitful to look across neuro-
genic populations to evaluate instructional practices. However, as noted
earlier, the outcomes were less clear for the dementia population; many of
these studies had qualified treatment effects. Of the studies reporting qualified
findings across aetiology groups, most reported differential outcomes for
different memory severity levels (e.g., Evans et al., 2000; Riley & Heaton,
2000). Riley and Heaton’s (2000) study provides a clear example. They
showed that participants with poorer memories may benefit from more
gradual fading of cues while those with stronger memories may require
more rapid fading. However, a number of studies (e.g., Page et al., 2006;
Tailby & Haslam, 2003) showed benefits of errorless learning across
memory severity levels. The question of how severity of memory impairment
affects candidacy for specific instructional practices remains equivocal.
The role played by an individual’s cognitive profile in domains other than
memory (e.g., attention, executive functions, awareness) is equally unclear.
There is some evidence that clients with frontal lobe damage and concomitant
impairments in awareness and executive functions may benefit less from the
method of vanishing cues and errorless techniques than patients with less
frontal lobe dysfunction (e.g., Clare et al., 2002; Leng et al., 1991). Andrewes
and Gielewski (1999) address this issue in their detailed report of positive
outcomes following the training of vocational skills in a person with dense
amnesia resulting from herpes encephalitis. They qualify their findings,
noting that the participant’s spared executive functions, high premorbid intel-
ligence, and intact semantic memory may have allowed her to benefit from
the training and achieve successful return to work. What is evident across
studies is the need for therapists to employ instructional techniques
matched to specific client cases and measure the ongoing effects of learning
in order to adjust instructional practices as necessary. Experimental evalu-
ation of candidacy issues is an important goal for future clinical research.
RECOMMENDATIONS
The instructional literature clearly demonstrates that structuring the manner
in which target information or procedures are introduced and reviewed can
facilitate learning. By implication, careful planning of how to train and
instruct people with damaged learning systems allows clinicians to optimise
experience-dependent learning. The review of the best current evidence
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suggests there are a number of key instructional practices that can promote
learning for individuals with acquired memory impairments. These include:
. Clear delineation of intervention targets and/or use of task analyses
when training multi-step procedures.
. Constraining errors and controlling client output while acquiring new or
relearning information and procedures.
. Providing sufficient practice.
. Distributing practice.
. Use of stimulus variation (e.g., multiple exemplars).
. Use of strategies to promote more effortful processing (e.g., verbal
elaboration; imagery).
. Selection and training of ecologically valid targets.
While there is substantial evidence to encourage clinicians to incorporate
and evaluate the effects of these instructional techniques, we run the risk of
being overly simplistic if we look to the evidence to identify the single,
right instructional practice(s). Learning is complex and we must recognise
that specific task, training, and learner characteristics will require different
combinations of instructional practices. Riley and Heaton (2000, p. 147)
eloquently remind clinicians and researchers that:
. . . the most effective [instructional] approach to teaching in any given
set of circumstances is likely to be a package that combines several
strategies in an attempt to facilitate a range of key processes and
which is tailored to the needs of the learning circumstances. From
this perspective, it is inappropriate to pose research questions about
whether one teaching strategy is more effective than another in some
absolute sense divorced from the circumstances.
We conclude with a call to clinicians to examine their instructional and
training practices and to be deliberate and systematic in their treatment plan-
ning. Clinicians typically do not view themselves as the designers and con-
veyors of curricula. However, this is ultimately what must occur in order to
implement the instructional procedures supported in the literature. The use
of instructional design and delivery principles that have been experimentally
validated are the key to successfully teaching or re-teaching procedures and/or knowledge to clients with memory impairments.
EVIDENCE-BASED PRACTICE GUIDELINES FOR INSTRUCTION 27
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APPENDICES
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