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Mary Kennedy, The ASHA Leader (page 2 of 3) Page 2 of 3
Assessing Memory and Metamemory
SLPs are a part of an interdisciplinary team that assesses memory skills. The assessment process typically includes formal, standardized evaluation tools that provide information about the individual's memory impairment. For practice guidelines on the use of standardized assessment for individuals with TBI, readers are referred to Turkstra et al. (2005).
Informal assessment provides SLPs with information about individuals' awareness of their memory problems and whether everyday forgetting is related to poor self-monitoring or self-control. Self-other questionnaires, structured interviews and systematic observation during functional activities are particularly useful for assessing TBI survivors' beliefs about their memory. For example, the Everyday Memory Questionnaire (Sunderland, Harris, & Baddeley, 1983) can be filled out by the TBI survivor and a family member or clinician independently and then compared to see if their perceptions match. (Clinicians should be aware that not all individuals are good judges of others' behavior. This is a caveat to the use of self-other questionnaires for assessing awareness.)
Interviews can be conducted by gradually asking more specific questions about clients' perceptions of their memory. Clinicians can begin with a question such as, "Do you have any memory problems?" and gradually asking such questions as, "What types of things do you forget? Do you use anything to help you remember and if so, what are they?" These queries provide SLPs with information about the breadth and depth of a client's awareness. By adding a Likert rating scale to the interview, valuable information can be obtained about how certain a client feels about the answers. Clinical observation of what the client does during complex activities that tax memory then should be compared to questionnaire information and answers from the interview.
Treatment Principles and Techniques
The mechanic knows that having the right tools for the job is important. The mechanic also knows that certain tools are better suited than others for specific tasks. Having tools, however, does not mean you will use them.
- External Memory Aids. Like the mechanic, individuals with TBI need a toolbox of strategies to help them avoid various kinds of memory failure. External memory aids are "supports" used to compensate for forgetfulness. These aids include everything from signs, calendars and daily planners (including PDAs), alerting systems, procedural checklists, etc. External memory aids are effective in preventing memory failure when a personalized approach is used in which clients help select the aid, while the clinician shapes its use and fades the cues. For a description of evidence for the use of external memory aids, readers are referred to Sohlberg et al. (in press).
- Internal Memory Aids. Internal memory aids are mental strategies used to enhance memory and improve the likelihood that information will be recalled later. These include visual imagery, elaborative encoding, grouping, etc. Self-created personalized visual images can be effective in improving recall for specific kinds of activities, such as remembering someone's name (e.g., Kashel et al, 2002). For example, if trying to remember the name "Cliff," an internal image of a person standing at a cliff's edge could facilitate memory. Elaborative encoding involves associating elements or features with the to-be-remembered item (e.g., Oberg & Turkstra, 1998). Grouping or chunking can be used when a lot of material needs to be remembered. By organizing the information into logical categories, individuals are more likely to remember the category, which then facilitates recall of the items within that category.
Metamemory Intervention
Impaired metamemory will affect whether or not memory aids are used. Alternatively, knowing that you have memory problems does not mean you will automatically use the aids introduced in treatment. For a description of evidence for intervention for executive function and metacognitive disorders, readers are referred to Kennedy et al (under review). Several intervention techniques are available that can facilitate accurate metamemory in survivors of TBI and thereby improve the likelihood that memory aids will be used:
- Individualize educational information about the client's specific memory and cognitive disabilities. There is little evidence that self-awareness improves when an individual is presented with general educational information. Individuals with TBI need individualized, specific information about their abilities and disabilities, so that they do not have to figure out what applies to them and what does not.
- Involve the client in setting memory goals and in selecting memory aids. See Webb and Gluecauf (1994) for an example of high-goal involvement and low-goal involvement. Those who were highly involved were better at setting goals two months after treatment ended, compared with those who were less involved.
- Create opportunities for accurate self-monitoring. Regardless of brain injury or frontal lobe injury, adults are very accurate at predicting their memory when the predictions are slightly delayed (Kennedy & Yorkston, 2004). When predictions are made immediately after or during studying (within about 30 seconds), our predictions are barely above chance. Clinicians can create an opportunity for accurate self-monitoring by forcing a delay between, for example, studying a grocery list and asking clients to predict how many items they will remember. If they predict that they will remember very few items, they can be directed by the clinician to use a memory aid. Thus, the link between self-monitoring and self-control is made explicit. Additionally, by showing the client how accurate they can be when making delayed predictions compared with immediate predictions, we give the client positive, direct feedback that they can be "good" at judging their learning. See Dunlosky, Hertzog, Kennedy & Thiede (2005) [posted online] for a description of a self-monitoring approach to effective learning across adult populations.
From Kennedy, M. Managing Memory and Metamemory Impairment in Individuals with Traumatic Brain Injury. The ASHA Leader, 11(14), 8-9, 34-36. Reprinted with permission. www.asha.org.
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