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NeuropsychologicalRehabilitation: An InternationalJournalPublication details, including instructions for authorsand subscription information:http://www.tandfonline.com/loi/pnrh20

Rehabilitation of everydaymemory deficits in paediatricbrain injury: Self-instruction anddiary trainingJoanna Ho a , Adrienne Epps b , Louise Parry b , MiriamPoole b & Suncica Lah aa School of Psychology, University of Sydney, NSW,Australiab Brain Injury Rehabilitation Program, SydneyChildren's Hospital (Randwick), NSW, AustraliaPublished online: 01 Feb 2011.

To cite this article: Joanna Ho , Adrienne Epps , Louise Parry , Miriam Poole & SuncicaLah (2011) Rehabilitation of everyday memory deficits in paediatric brain injury: Self-instruction and diary training, Neuropsychological Rehabilitation: An InternationalJournal, 21:2, 183-207, DOI: 10.1080/09602011.2010.547345

To link to this article: http://dx.doi.org/10.1080/09602011.2010.547345

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Rehabilitation of everyday memory deficits in

paediatric brain injury: Self-instruction and

diary training

Joanna Ho1, Adrienne Epps2, Louise Parry2, Miriam Poole2,and Suncica Lah1

1School of Psychology, University of Sydney, NSW, Australia2Brain Injury Rehabilitation Program, Sydney Children’s Hospital

(Randwick), NSW, Australia

Memory problems that interfere with everyday living are frequently reported inchildren who have sustained acquired brain injury (ABI), but their nature andrehabilitation is under-researched. This study aimed to (1) determine neuropsy-chological correlates of everyday memory deficits in children with ABI, and(2) investigate the effectiveness of a newly developed programme for theirrehabilitation. We assessed everyday memory, verbal memory, attention andbehaviour in 15 children with ABI. The children attended the everydaymemory rehabilitation programme: six weekly sessions that involved diarytraining, self-instruction training and case examples. At the onset we foundthat everyday memory problems were related to impaired attention andbehavioural difficulties. On completion of the programme there was a signifi-cant increase in children’s abilities to perform daily routines that demandedrecall of information and events. In addition, children used diaries morefrequently. Moreover, significant secondary gains were found in attentionand mood (anxiety and depression). In conclusion, the results providedpreliminary evidence that our six week programme could be effective inreducing everyday memory difficulties and improving psychological well-being in children with ABI.

Keywords: Memory; Rehabilitation; Child; Brain injury.

Correspondence should be sent to Suncica Lah, Mungo Mac Callum Building (A19), School

of Psychology, University of Sydney NSW 2006, Australia. E-mail: suncica.lah@sydney.edu.au

We would like to thank the children and their families who took part in this study.

NEUROPSYCHOLOGICAL REHABILITATION

2011, 21 (2), 183–207

# 2011 Psychology Press, an imprint of the Taylor & Francis Group, an Informa business

http://www.psypress.com/neurorehab DOI:10.1080/09602011.2010.547345

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INTRODUCTION

Acquired brain injury (ABI) is a common cause of disability during childhood.For example, in Australia 93 per 100,000 children under the age of 15 wereadmitted to hospital with traumatic brain injury (TBI) per year in 2004–2005 (O’Rance, 2007). Outcome studies have shown that memory impair-ments are often found on neuropsychological testing (Catroppa & Anderson,2002, 2007) and memory problems represent the most frequently reported sub-jective deficits by children and adults with ABI (Kinsella et al., 1996; Levin,Benton, & Grossman, 1982; Mateer, Sohlberg, & Crinean, 1987). In adultswith ABI some studies found a significant correlation between patients’level of memory complaints and scores obtained on standardised neuropsy-chological memory tests (i.e., Ownsworth & McFarland, 1999), but manydid not (Kapur & Pearson, 1983; Kinsella et al., 1996; Sunderland, Harris,& Baddeley, 1983). Instead, they found subjective memory complaints to bemainly related to factors such as mood (Chamelian & Feinstein, 2006) andprospective memory (Kinsella et al., 1996). The underpinnings of memorycomplaints have not been investigated in children with ABI. For a numberof reasons we cannot assume that cognitive and psychological underpinningsof reported difficulties with everyday memory in children with ABI are thesame as in adults with ABI. Firstly, children and adults differ with respectto memory capacity and types of demands being placed on their memory ineveryday life. Secondly, physiological responses to ABI are influenced bymaturation stage of the human brain. Thirdly, the rate and pattern of recoveryfollowing a brain insult are different to that of adults (Anderson, Catroppa,Morse, Haritou, & Rosenfeld, 2005; Anderson & Moore, 1995; Anderson,Morse, Catroppa, Haritou, & Rosenfeld, 2004; Gronwall, Wrightson, &McGinn, 1997; Hessen, Nestvold, & Anderson, 2007; Taylor et al., 2002).

In the only study that examined the relationship between memory com-plaints and performance on neuropsychological tests in children, Kadis,Stollstorff, Elliot, Lach, and Smith (2004) found that parental reports ofattentional deficits, but not scores obtained on a number of other standardisedcognitive or behavioural measures, accounted for a significant proportion ofvariance in everyday memory in patients with intractable epilepsy. Thesefindings, however, cannot be automatically generalised to children withABI, as the two disorders impact children’s brain and cognitive developmentin different ways. In children with ABI, brain damage is sustained at the timeof insult and is followed by recovery. Once the acute stage of recovery iscomplete these children usually make cognitive gains at a steady, albeitsomewhat reduced rate (Jaffe, Polissar, Fay, & Liao, 1995). In childrenwith epilepsy, seizures may occur over many years and may have a cumulat-ive negative effect on brain development (Hermann et al., 2002). In somecases this may result in deceleration of cognitive development over time

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(Lah, 2004). Moreover, seizures themselves may intermittently disrupt acqui-sition and consolidation of memories (Kapur, 1997).

Everyday memory requires memory formation (registration, learning, andretention of information), but also utilisation of this information. While thecore memory formation processes are measured by standardised neuropsycho-logical tests, the testing is usually conducted in a highly structured, controlledenvironment with minimal distracters (Kadis et al., 2004). In contrast, at schooland at home, children are in situations when competing stimuli are present sim-ultaneously. They need to select relevant from irrelevant information andmaintain attention on that information so as to register, learn and retainmaterials and instructions. In order to utilise this information appropriately,children need to keep information on hold, switch between different trains ofthought, and utilise remembered information when relevant environmentalcues are presented. Thus attentional difficulties, which are very commonfollowing paediatric ABI (e.g., Catroppa, Anderson, Morse, Haritou, &Rosenfeld, 2006; Park, Allen, Barney, Ringdahl, & Mayfield, 2009; Yeates &Enrile, 2005), are likely to have a significant impact on children’s everydaymemory functioning. In addition, children with ABI are at an increased risk ofdifficulties with mood (Donders & Ballard, 1996; Luis & Mittenberg, 2002;Max, Bruce, Keatley, & Delis, 2010), which is likely to impact their overalllevel of alertness, ability to initiate mental search and utilise cognitive skillswhen needed. Thus, in children with ABI, everyday memory difficulties maybe secondary to problems with memory formation, attention and mood.

Rehabilitation of memory difficulties

The ultimate goal of rehabilitation is to improve patients’ everyday function-ing. Memory difficulties interfere with the completion of tasks in everydaylife, such as remembering instructions, conveying messages, or completingdaily tasks. This type of difficulty produces a high level of dependency anda heavy long-term burden on carers (Kersel, Marsh, Havill, & Sleigh, 2001;Marsh, Kersel, Havill, & Sleigh, 1998). Early adult memory interventionstudies worked on development of particular strategies to enhance leaningand retention of information over time (see Mateer & Sohlberg, 1988).These studies have shown some benefits of such a training in a laboratoryand rehabilitation setting, but the generalisation of these skills to everydayactivities has been limited (Mateer & Sohlberg, 1988). Subsequent studiesindicated that training in use of memory aids (i.e., diaries) improved cognitivefunctions such as attention and memory, and compensated for deficits ineveryday memory (NIH Consensus Panel, 1999).

The use of diaries was found to be enhanced and everyday memory problemsfurther reduced when diary training was combined with self-instructionaltraining, which utilised higher level skills of self-regulation and self-awareness

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(Ownsworth & McFarland, 1999). This study involved 20 adults (M ¼ 43.1years) who were recruited via a local brain-injury community support group.Participants were all in the chronic stage of recovery post-ABI (M ¼ 15years; minimum 4 years post-injury), which were in most (but not all) cases sus-tained in motor vehicle accidents. They completed a self-report memory ques-tionnaire that included items describing frequent everyday memory problemsand were randomly assigned into one of two treatment groups: diary only ordiary and self-instruction training. The between-group difference in the totalnumber of diary entries made by the two groups was not significant. Neverthe-less, subjects who participated in the combined (diary and self-instruction) train-ing reported lower levels of distress associated with memory problems and agreater use of strategies during and after treatment relative to baseline con-ditions. The self-instructional training (SIT) component of the programmearose from a cognitive top down model initially derived by Meichenbaum andCameron (1973). The SIT was found to be effective in developing attentionalcontrol in people with schizophrenia (Meichenbaum & Cameron, 1973),reducing difficulties with attention and memory in adults with closed headinjury (Webster & Scott, 1983), and increasing impulse control in children(Meichenbaum & Goodman, 1971). Moreover, Bornstein and Quevillon(1976) found that three overactive four-year-olds were able to generalise theirself-instruction to classroom on-task behaviour.

Memory rehabilitation studies that involved children and adolescents withABI have been sparse and have mainly included single case studies (Brett &Laatsch, 1998; Franzen, Roberts, Schmits, Verduyn, & Manshadi, 1996;Lawson & Rice, 1989; Oberg & Turkustra, 1998). These used individuallytailored interventions for specific memory impairments. At the time ourstudy was developed there was only one published study examining the effi-cacy of a memory (and attention) training programme in a group of childrenwith ABI; the Amsterdam Memory and Attention Training for children(Amat-c; van’t Hooft et al., 2005; van’t Hooft, Andersson, Sejersen,Bartfai, & von Wendt, 2003). The programme, which was initially developedand used (Hendriks, 1996; Hendriks & van den Broek, 1996) for remediationof attention of memory difficulties in children treated for cancer, was modi-fied and delivered individually. It involved exercises in specific attention andmemory techniques. It required 30 minutes of daily practice, which involved acoach (teacher or parent) and a child, over a 17-week period. In addition, thechild and the coach were seen at the hospital for feedback once a week.Although significant improvements were found on tests of attention andmemory on completion of the Amat-c, this approach was not used in ourstudy for three main reasons: (1) it placed a very high demand on resources,(2) it was not available in the English language, and (3) it was unknownwhether attention and memory gains that were apparent on testing generalisedto everyday life. Recently, three studies examined efficacy of external

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memory aids in children and adolescents with memory and organisation/planning problems following ABI (DePompei et al., 2008; Gillette & DePom-pei, 2008; Wilson et al., 2009). All three studies found statistically significantimprovements in targeted behaviours on completion of training and reportedthat participants’ independence increased. None of these studies used aninternal strategy that could enhance efficacy of external aids. Moreover,they did not establish whether significant changes in underlying cognitiveskills or secondary cognitive or psychological gains also took place.

When developing our programme we adopted an approach that used a com-bination of external and internal strategies: diary and self-instructional training(DSIT). We thought that such an approach may improve attention, enhance self-regulation skills and teach simple behaviours associated with diary use. By gen-eralising the use of self-instruction to everyday living, it can be argued thatchildren will be able to apply an appropriate strategy to compensate for theirmemory difficulties, reduce failures, increase self-esteem, and improvemood. In addition, better self-regulation may result in secondary cognitivegains, such as reduced distractibility and improved attention. We were awarethat the rehabilitation of memory problems in children needed to be sensitiveto the limitations which developmental and intellectual abilities place on boththe acquisition and use of diaries. Moreover, materials needed to be of relevancefor children whose academic, social and recreational activities differ from thoseof adults. In addition, materials and techniques needed to be socially and devel-opmentally appropriate, so the children do not stand out from their peers.

In all, while memory deficits are frequently reported by parents of childrenwith ABI, their cognitive and behavioural underpinnings have not been ident-ified, and rehabilitation of memory deficits has been greatly under-researchedin this patient population. Thus the main aims of the current study were to (1)investigate behavioural and cognitive correlates of everyday memory com-plaints, (2) develop a paediatric everyday memory rehabilitation programmeusing a diary and self-instructional training approach, and (3) examine the effi-cacy of the newly developed rehabilitation programme on everyday memory inchildren with ABI. Overall, we predicted that in children with ABI, difficultiesin everyday memory will be associated with problems with memory formationas well as with attention and mood. The programme was expected to reduceeveryday memory difficulties and improve children’s attention and mood.

METHOD

Participants

Fifteen children (seven boys and eight girls) aged 11–17 years (M ¼ 13years) who had sustained a significant ABI 12 months prior to recruitment

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participated in the study. The severity of injury was classified as follows: (1)mild ABI (n ¼ 4): Glasgow Coma Score (GCS; Teasdale & Jennett, 1974) of13–15 on admission and/or post-traumatic amnesia (PTA; Brown & Nell,1991) ,1 hour, no evidence of mass lesion on computed tomography (CT)or magnetic resonance imaging (MRI), and no neurological deficits; (2) mod-erate ABI (n ¼ 3): GCS of 9–12 on admission and/or PTA of 1–24 hours,and/or evidence of specific brain injury on CT/MRI; and (3) severe ABI(n ¼ 8): GCS of 3–8 on admission and/or PTA . 24 hours and evidenceof specific injury on CT/MRI. The injuries were caused by: motor vehicleaccidents (n ¼ 4), falls (n ¼ 4), strokes (n ¼ 3), near drowning accidents(n ¼ 2), sporting accident (n ¼ 1) or infection (n ¼ 1).

Only children who displayed difficulties in everyday memory with scoreswithin or below the low average range (, –0.6z; Lezak, Howieson, Loring, &Hannay, 2004) on the Parent (M ¼ –1.87; SD ¼ 1.11) or Child (M ¼ –0.94;SD ¼ 1.11) Memory Questionnaire (Kadis et al., 2004; Vriezen & Smith,1996) were included in the study. Additional inclusion criteria were: (1) nohistory of major pre-existing psychiatric or neurological illness (i.e.,autism, epilepsy, cerebral palsy); (2) Full-Scale Intelligence Quotient(FSIQ) .79 on the Wechsler Intelligence Scale for Children – FourthEdition (WISC-IV; Wechsler, 2003) or Wechsler Abbreviated Scale ofIntelligence (WASI; Wechsler, 1999); (3) fluent in the English language;and (4) reading skills ≥ Year 3, as measured on the Wechsler IndividualAchievement Test – Second Edition (WIAT-II; Wechsler, 2002), so childrencould read diary entries. Demographic information can be seen in Table 1.

All children were managed by the Brain Injury Rehabilitation Program(BIRP) at the Sydney Children’s Hospital (SCH) in Randwick. Developmen-tal and medical history was obtained through review of medical records and

TABLE 1Demographic information

Mean Range

Age at Pre-treatment (years) 13.43 11–17.42

Mother’s years of education 13.27 10–18

Injury severity (GCS) 9.33 3–15

Age at injury (years) 7.62 1.92–16.00

Time since injury (years) 5.79 1.42–12.25

FSIQ (scaled score) 101.73 89–128

Word reading (scaled score) 97.29 66–116

PMQ (Pre-treatment z-scores) 21.88 24.26– 20.24

CMQ (Pre-treatment z-scores) 20.94 21.64–0.51

Note: GCS ¼ Glasgow Coma Scale; FSIQ ¼ Full Scale Intelligence Quotient; PMQ ¼ Parent

Memory Questionnaire; CMQ ¼ Child Memory Questionnaire

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semi-structured interviews with caregivers. The study was approved by theUniversity of Sydney Human Research Ethics Committee and the SCHHuman Research Ethics Committee.

Materials

Everyday memory. The Parent Memory Questionnaire (PMQ; Vriezen &Smith, 1996) and Child Memory Questionnaire (CMQ; Kadis et al., 2004)were used to evaluate perceived memory difficulties in everyday life. Eachquestionnaire consists of 28 items on which children’s abilities to rememberinformation and events in the context of their daily routines are rated on afive-point scale ranging from “never true” to “usually true”. The resultsobtained by Vriezen and Smith (1996) in a group of healthy children wereused to calculate z-scores for the PMQ. As no normative data were availablefor the CMQ, scores from 16 healthy control children (HC, nine siblings andseven from the community) aged 11–19 years (M ¼ 15 years) were used tocalculate z-scores for this version of the questionnaire. HC children had nohistory of neurological (including head injury), psychiatric or developmentaldifficulties. A chi square analysis revealed that the HC group (eight boys andeight girls) did not differ significantly from the ABI group in gender distri-bution, x2(1, 1) ¼ 0, p ¼ 1.0. Moreover, one-way ANOVAs indicated thatthe between group differences in age (M ¼ 15.00; 11–19 years) andmother’s years of education (M ¼ 12.94; 10–15 years) were not significant,F(1, 29) ¼ 0.07, p ¼ .61.

School diaries were used by all children prior to treatment. Six childrendecided to continue using their pre-existing school diaries and nine optedfor a new one that was provided by the instructor. School diaries were slightlymodified so that the structure of all diaries was the same. Every diary includeda Name and Information cover, an A4 sized fold-out yearly calendar and fivetabbed sections: Diary Planner, How To, Notes, Transport and Address. Diaryentries were evaluated using detailed diary scoring criteria (available onrequest) developed by the main investigator (JH). One third (5/15) of ran-domly chosen diaries were scored by an independent rater (SL). Inter-raterreliability was found to be very high (r ¼ .99).

Cognition. Intelligence and reading were assessed using the WISC-IV(Wechsler, 2003) or the WASI (Wechsler, 1999) and the Word Readingsubtest from the WIAT-II (Wechsler, 2002), respectively. The Full ScaleIntelligence Quotient (FSIQ) from the tests of intelligence and the standardscores from the reading subtest were used in the study.

Anterograde memory was evaluated using the Rey Auditory Verbal Learn-ing Test (RAVLT; Rey, 1964), which includes two lists of words: List A andList B. The test requires children to recall the words immediately after each

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presentation. List A is read first, five times in a row. List B is read next, onlyonce. This is followed by the immediate and 20 minutes delayed recall ofList A. The following raw scores were considered in the study: number ofwords recalled after the first presentation of list A (Trial 1), total numberof words repeated across learning trials of List A (Total score) and numberof words recalled after 20 minutes (Delayed recall). Subsequently rawscores were transferred into z-scores using Taylor (1959) norms.

Attention was examined with selected subtests of the Test of EverydayAttention for Children (TEAch; Manly, Robertson, Anderson, & Nimmo-Smith, 1999): Sky Search (number of correctly identified targets, time pertarget, attention), Score, Creature Counting (total correct, timing score) andSky Search Divided Task (dual task decrement), which are representativeof four attentional factors covered by this test: selective/focused attention,sustained attention, attentional control/switching, and sustained-dividedattention, respectively (Baron, 2004). In all instances aged-related standardscores were considered for the study.

Behaviour. The Child Behaviour Checklist (CBCL) and Youth Self-Report (YSR) (Achenbach & Rescorla, 2001) were completed by parentsand children, respectively. Internalising and Externalising standard compositescores (T scores) were considered for the study.

Treatment manual. Participants were provided with an 84-page treatmentmanual that was developed by the main investigator (Ho, 2006). The treat-ment manual was divided into six sections, one for each week of theprogramme. It consisted of example scenarios and practice exercises thatwere tailored for children and appeared to have real world salience. Theseexamples ranged from simple, e.g., writing a given list of homework taskscorrectly into a mock diary using a colour coding system, to more complexexamples, such as identifying mistakes and rewriting short stories aboutforgetful children. See a brief outline of the programme in Appendix 1.

Procedure

All participants were assessed at three different time-points: pre-treatment(M ¼ 4.1 weeks before treatment commenced; SD ¼ 2.2), post-treatment(M ¼ 2.2 weeks after completion of treatment; SD ¼ 1.3), and at follow-up(M ¼ 13.3 weeks after completion of treatment; SD ¼ 4.3).

Pre-treatment. Participants were individually administered everydaymemory (CMQ) and behavioural (YSR) questionnaires, as well as tests ofcognition in the set order: RAVLT, TEAch, WASI and WIAT-II. Entriesmade in the school diaries over the period of two months prior to assessment

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were examined; double baseline was obtained by evaluating diary entriesmade in the first and last two weeks of this period. Parents completedeveryday memory (PMQ) and behavioural (CBCL) questionnaires.

Treatment. Treatment comprised six 1.5-hour sessions delivered overconsecutive weeks. The memory training programme was run individuallyor in a small group (maximum three children) by the same instructor through-out the training. Participants were provided with the treatment manual in thefirst session. The training involved self-instruction and diary training.

Self-instructional training involved learning a set of internal steps (pre-viously used by Ownsworth & McFarland, 1999). These were: W – What areyou going to do? (Analysis); S – Select a strategy for the task (StrategySelection); T – Try out the strategy (Strategy Initiation); C – Check out howthe strategy is working (Monitoring) (WSTC). The potential benefits of usinga self-instructional strategy were discussed with the children before givingthem demonstrations, discussing case examples and practising the procedure.

Diary training included a three-stage approach (Acquisition, Applicationand Adaptation) proposed by Sohlberg and Mateer (1989). In the Acquisitionstage the children were taught the names, purpose and use of each section intheir diary. They were encouraged to check and use their diaries regularly. Inthe Application stage, children were given a large number of case studies androle plays to teach them when and where to use their diaries and self-instructional training. Since diary use itself may be a memory task, variousorganisation strategies were taught, such as using colour coding for diaryentries with bright colours or highlighting to emphasise important notes.Finally, in the Adaptation stage, skills utilisation in everyday life wasdiscussed and encouraged.

It has been suggested that memory rehabilitation is most effective whenparticipants are capable and motivated to continue active, independentstrategy use (Cicerone et al., 2000). Thus each week the participants wereencouraged to contribute to discussions of examples and strategies given inthe manual and to utilise the new skills outside the training session. Moreover,it has been pointed out that input from patients in the development ofmemory aids may result in better strategy use and compliance (Sunderland,Harris, & Baddeley, 1984). Therefore children were also asked to comeup with their own examples of everyday memory difficulties, think of strat-egies that can be used to compensate for these difficulties and test them ineveryday life.

Post-treatment. In this phase all behavioural and cognitive measures(except for tests of intelligence and reading) were re-administered in thesame order. To avoid practice effects parallel forms were used for all post-treatment cognitive assessments.

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Follow-up. To investigate the maintenance of treatment gains, everydaymemory questionnaires were re-administered and diary entries made over thelast two consecutive weeks were examined at a follow-up assessment.

Statistical analyses

All scores, except for diary use, were converted into z-scores (M ¼ 0, SD ¼1) considering normative data/manuals. When reporting the scores, theclassification of Lezak et al. (2004) was used to label test scores (+2 andabove ¼ very superior; +1.3 to +2 ¼ superior; +0.6 to +1.3 ¼ highaverage; 0 + 0.6 ¼ average; –0.6 to –1.3 ¼ low average; –1.3 to –2.0 ¼borderline; and –2.0 and below ¼ deficient). Of note, while high scores onthe cognitive tests and memory questionnaires indicated better performance,high scores on the behavioural questionnaires (CBCL, YSR) indicated worsepsychological functioning.

For all statistical analyses reported, an alpha level , .05 was used. Assump-tions of normality and Mulchly’s tests of sphericity were satisfactory. One-wayunivariate analysis of variance (ANOVA) was utilised to compare the numberof weekly diary entries made by children who used old diaries with those whoused new diaries during treatment. Wilcoxon matched pairs signed-ranked testswere conducted to compare ordinal data: pre-treatment ratings of children’severyday memory made by parents and children themselves.

To examine the effectiveness of the training programme one-way repeatedmeasure ANOVA was used when comparing (1) the weekly number of diaryentries made at pre-, post-treatment and follow-up (with post hoc comparisons),and (2) the scores obtained on cognitive tests at pre- and post-treatment.Wilcoxon matched pairs signed-ranked tests were conducted to evaluatechanges in the (1) everyday memory ratings from pre- to post-treatment andfollow-up, and (2) behavioural ratings from pre- to post-treatment.

Correlations were employed to examine: (1) relationships between scoresobtained on instruments measuring everyday memory, behaviour andcognition; and (2) whether pre-treatment cognitive and behavioural featurescorrelate significantly with changes in everyday memory from pre- to post-treatment. Pearson r correlations were calculated between the weeklynumber of diary entries and scores obtained on cognitive tests. In all otherinstances Spearmen rank correlations were obtained.

RESULTS

Pre-treatment

Scores obtained on measures of everyday memory are given in Figure 1. Themean caregivers’ and children’s responses on the PMQ and CMQ fell in the

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borderline and low average ranges, respectively. A Wilcoxon test revealedthat the PMQ ratings were significantly lower than the CMQ ratings (z ¼–2.05, p , .05). A one-way repeated measure ANOVA indicated no signifi-cant change, F(1, 13) ¼ 1.27, p . .05, in the number of diary entries made inthe first (M ¼ 6.00, SD ¼ 4.84) and the last (M ¼ 7.82, SD ¼ 6.25) twoweeks of the two month period before treatment. This suggested that theuse of diaries did not increase spontaneously pre-treatment. Thus the

Figure 1. Means and standard deviations of: (a) scores obtained on the Parent Memory Questionnaire

(PMQ) and Child Memory Questionnaire (CMQ) and (b) weekly number of diary entries (Diary Use).∗ indicates a significant difference at p , .05. Whiskers indicate standard errors of measurement.

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average number of diary entries made over these four weeks was used as abaseline.

Scores obtained on measures of cognition and behaviour are shown inTable 2. Mean scores obtained on the TEAch - Score and Sky SearchDivided Task fell in the low average range. Scores obtained on all other cog-nitive measures were in the average range. The mean behavioural ratings onthe CBCL and YSR fell in the low average range on the Internalising andExternalising, and Internalising (but not Externalising) behavioural compo-sites, respectively.

Correlations between scores obtained on everyday memory questionnaires,diary entries and scores obtained on cognitive and behavioural measures aregiven in Table 3. Only the CMQ, but not the PMQ or diary use, correlatedsignificantly with measures of cognition and behaviour. Scores on theCMQ were significantly correlated with scores obtained on the TEAch -Sky Search (time: r ¼ .52, p , .05) and Creature Counting (time: r ¼ .53,p , .05); greater difficulties in everyday memory were associated withpoorer attention. Furthermore, scores on the CMQ were significantly, butnegatively correlated with Internalising behavioural problems as reported

TABLE 2Mean scores (standard deviations) obtained on the cognitive and behavioural instruments

at Pre- and Post-treatment

Measure Pre-treatment Post-treatment

RAVLT

Trial 1 20.07 (1.38) 1.01 (1.47)

Total score 0.79 (1.12) 1.39 (1.66)

Delayed recall 0.79 (1.48) 0.80 (2.23)

TEAch

Sky Search - correct 0.58 (0.74) 0.31 (1.05)

- time 20.42 (0.62) 0.13 (0.99)

- attention 20.20 (0.56) 0.22 (0.95)

Score 20.69 (0.85) # 20.76 (0.88)#

Creature Counting - correct 0.13 (0.78) 0.56 (0.50)

- time 20.40 (0.94) 20.04 (0.92)

Sky Search Divided Task 21.00 (0.81)# 20.82 (0.89)#

CBCL

Internalising 1.13 (1.11)# 0.81 (1.07)#

Externalising 0.89 (1.00)# 0.65 (0.97)#

YSR

Internalising 0.75 (1.11)# 0.31 (1.01)

Externalising 0.44 (0.82) 0.23 (1.00)

Note: RAVLT ¼ Rey Auditory Verbal Learning Test; TEAch ¼ Test of Everyday Attention for

Children; CBCL ¼ Child Behaviour Checklist; YSR ¼ Youth Self Report.# low average ¼ –0.6 to –1.3 z; except for CBCL and YSR where low average ¼ 0.6 to 1.3 z

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on the CBCL and YSR (r ¼ –.57 and r ¼ –.62 respectively, p , .05 inboth instances): high levels of internalising problems were significantlyassociated with poorer everyday memory. Other correlations were notsignificant (p ≥ .05).

Post-treatment and follow-up

Figure 1 also contains scores obtained on measures of everyday memorypost-treatment and on follow-up. Wilcoxon tests indicated statistically signifi-cant increases in the PMQ and CMQ scores post- compared to pre-treatment(z ¼ –2.19, p , .05 and z ¼ –1.98, p , .05, respectively) but no significantchange at follow-up relative to post-treatment (p ¼ .64 and p ¼ .67,respectively) or pre-treatment (p ¼ .16 and p ¼ .22, respectively).

TABLE 3Pre-treatment correlations between scores obtained on measures of everyday memory,

and results gained on instruments assessing cognition and behaviour

Measure PMQ CMQ Diary Use#

PMQ 1 2.04 2.10

CMQ 2.04 1 2.07

RAVLT

Trial 1 .08 2.29 .10

Total score .38 2.08 2.24

Delayed recall .16 2.19 2.52

TEAch

Sky Search - correct .17 .03 .24

- time 2.05 .52∗ 2.04

- attention 2.00 .49 2.17

Score 2.34 .15 .48

Creature Counting - correct 2.27 2.13 2.26

- time 2.03 .54∗ 2.03

Sky Search Divided Task 2.37 .31 .01

CBCL

Internalising 2.32 2.57∗ .05

Externalising 2.04 .17 2.31

YSR

Internalising 2.07 2.62∗ 1.18

Externalising .06 2.25 .27

Note: PMQ ¼ Parent Memory Questionnaire; CMQ ¼ Child Memory Questionnaire; Diary Use

¼ weekly number of diary entries; RAVLT ¼ Rey Auditory Verbal Learning Test; TEAch ¼ Test of

Everyday Attention for Children; CBCL ¼ Child Behaviour Checklist; YSR ¼ Youth Self Report.#Pearson r correlations were calculated between Diary Use and results obtained on cognitive

tests. In all other instances Spearmen rank correlations were used. ∗indicates a significant correlation,

p , .05.

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A one-way ANOVA showed that there was no significant difference,F(1, 13) ¼ 0.80, p ¼ .39, in the weekly number of diary entries madeduring the treatment by children who chose to continue using their schooldiaries (M ¼ 7.43, SD ¼ 5.08) and those who opted to use a new diary (M¼ 6.39, SD ¼ 4.63). This indicated that the novelty of new diaries did notresult in them being used more often than the already existing diaries. Thusno differentiation was made between diary entries made using new or olddiaries in the rest of the analyses.

Finally, a one-way repeated measure ANOVA revealed a statistically sig-nificant difference in the number of diary entries made at different times –pre-treatment, post-treatment and follow-up; F(2, 26) ¼ 5.67, p ¼ .02. Post-hoc analyses demonstrated a significant increase in the number of diaryentries from pre- to post-treatment (p , .01). There was no evidence of asignificant change in the weekly number of diary entries made at follow-upcompared to post- and pre-treatment (p ¼ .20, p ¼ .39, respectively).

Correlations between pre- to post-treatment changes on measures of every-day memory were non-significant, except for one; changes on the CMQ andweekly number of diary entries pre- to post-treatment correlated significantly(r ¼ .58, p , .05). An improvement in everyday memory was associatedwith an increase in the number of diary entries.

Secondary gains were investigated by comparing pre- to post-treatmentscores obtained on measures of cognition and behaviour that were not directlytargeted by the treatment. One-way repeated measure ANOVAs showed sig-nificant changes (improvements) on the Sky Search, time: F(1, 14) ¼ 10.54,p , .01; attention: F(1, 14) ¼ 5.53, p ¼ .03, and Creature Counting, correct:F(1, 14) ¼ 5.35, p ¼ .04. In addition, on the YSR, Wilcoxon tests indicatedthat children’s ratings of their Internalising (but not Externalising) behaviouralproblems dropped significantly from pre- to post-treatment (z ¼ –1.99p , .05) and the score was now within the average range. No significantchanges were observed on any other measures of behaviour or cognition.

Correlations between pre-treatment cognitive and behavioural scoreswith changes in everyday memory from pre- to post-treatment were givenin Table 4. A score on Trial 1 of the RAVLT was significantly correlated(r ¼ .53, p , .04) with a change in scores on the CMQ. On measures of atten-tion, the TEAch Creature Counting (correct) and Sky Search Divided Taskwere significantly correlated (r ¼ .74, p , .01 and r ¼ .58, p , .05, respect-ively) with changes on the PMQ. In both instances higher pre-treatment cog-nitive scores were associated with greater improvement in everyday memory.

A significant, but negative correlation was obtained between the TEAchSky Search (time: r ¼ –.68, p , .01 and attention: r ¼ –.88, p , .01) andchanges on the CMQ. Moreover, the TEAch Sky Search and CreatureCounting (time in both instances) were significantly and negatively correlatedwith changes in diary use (r ¼ –.62, p , .05 and r ¼ –.66, p ¼ .01,

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respectively). In these instances children with lower pre-treatment scoresmade greater gains in everyday memory.

With respect to behaviour, ratings of Internalising behaviour on the CBCLand the YSR at pre-treatment were significantly correlated with gains on theCMQ: r ¼ .76, p , .01 and r ¼ .68, p , .01, respectively. In addition,ratings of Externalising behaviour on the CBCL were significantly correlatedwith an increase in the weekly number of diary entries (r ¼ .53, p , .05).Overall, children with higher internalising behavioural problems pre-treatment improved more in everyday memory.

DISCUSSION

In this study we set out to investigate the nature of memory difficultieschildren with ABI are reported to experience in everyday life and to

TABLE 4Correlations between pre- to post-treatment changes on measures of everyday memory

and pre-treatment scores obtained on cognitive and behavioural instruments

Pre-treatment PMQ-C CMQ-C DU-C#

RAVLT

Trial 1 0.10 0.49 0.51

Total score 0.05 0.22 0.30

Delayed recall 0.04 0.12 0.22

TEAch

Sky Search - correct 20.03 20.26 0.13

- time 0.26 20.68∗∗ 20.62∗

- attention 0.13 20.88∗∗ 20.47

Score 0.33 20.24 20.49

Creature Counting - correct 0.73∗∗ 20.32 20.34

- time 20.07 20.47 20.66∗

Sky Search Divided Task 0.58∗ 20.26 20.42

CBCL

Internalising problems 20.26 0.76∗ 0.44

Externalising problems 20.27 20.05 0.48

YSR

Internalising problems 20.22 0.68∗ 0.52

Externalising problems 20.51 0.08 0.53∗

Note: PMQ-C ¼ Parent Memory Questionnaire (PMQ) post-treatment – PMQ pre-treatment;

CMQ-C ¼ Child Memory Questionnaire (CMQ) post-treatment – CMQ pre-treatment; DU-C ¼

weekly number of diary entries post-treatment – weekly number of diary entries pre-treatment;

RAVLT ¼ Rey Auditory Verbal Learning Test; TEAch ¼ Test of Everyday Attention for Children;

CBCL ¼ Child Behaviour Checklist; YSR ¼ Youth Self Report.#Pearson r correlations were calculated between the Diary Use and results obtained on cognitive

tests. In all other instances Spearmen rank correlations were used. ∗ and ∗∗ indicate significant corre-

lations at p , .05 and p , .01, respectively.

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evaluate the efficacy of a programme specifically developed for theirrehabilitation.

Neurobehavioural correlates of everyday memory complaints

This study is, to our knowledge, the first to examine cognitive and behaviour-al correlates of memory complaints in children with ABI. Children’s (but notparents’) subjective impressions of everyday memory problems, as assessedusing the everyday memory questionnaire, were associated with scoresobtained on tests of attention and ratings of internalising behaviours. Thatis, children who reported poor everyday memory had reduced attention andgreater internalising behavioural problems.

In the current study no correlation was found between anterograde memoryand reported memory difficulties in everyday life. While this is consistentwith many adult studies (Brown, Dodrill, Clark, & Zych, 1991; Schwartz &McMillan, 1989), it is important to note that children who were included inour study had little evidence of anterograde memory deficits, and memoryassessment was limited to verbal memory. Nevertheless, this is unlikely toexplain completely the lack of correlation; Kadis et al. (2004) pointed outthat standardised, clinically used memory tests may not be accurate predictorsof everyday memory, as testing is usually done in a quiet, highly structuredand controlled environment. In contrast, multiple distracters and competingdemands are simultaneously present in everyday life. Thus even informationthat is adequately stored may not be retrieved at the right time, especially inchildren who have difficulties with attention, speed of processing and mentalflexibility, which are frequently found in children with ABI (Anderson &Pentland, 1998; Catroppa et al., 2006; Levin et al., 1994). In addition, it islikely that children who have difficulties with attention and behaviour aremore challenging to parent and were more likely to be referred to the pro-gramme. Indeed, children involved in our study were found to have somewhatreduced attention and increased behavioural difficulties relative to normativedata. In the current study children with poor selective/focused attention (SkySearch, attention) and slower information processing on the task that requiredmental tracking and switching of attention (Creature Counting time) weremore likely to report greater difficulties with memory. It has been suggestedthat selective attention becomes crucial when there is competition betweenstimuli in the environment (Chun & Turk-Browne, 2007), which is oftenthe case in everyday living. Thus patients with ABI are likely to displaymemory impairments due to limited attentional resources to allocate to taskperformances (Schmitter-Edgecombe, 1996) and information overloadsecondary to reduced speed of information processing in these cognitivelydemanding situations.

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We found significant correlations between children’s subjective reports ofeveryday memory difficulties and internalising behavioural problems (com-posite score that includes scales assessing depressed/withdrawn behavioursand anxiety on the CBCL and YSR). As stated earlier, children who reportedgreater everyday memory difficulties also experienced greater behaviouralproblems, which is consistent with the result of the study that includedadult patients with ABI (Chamelian & Feinstein, 2006). While it is possiblethat memory difficulties are in part due to an underlying mood disorder, ithas been pointed out that the relationship between mood and subjectivememory deficits is not unidirectional. On the one hand, patients with mooddisorders have been found to frequently report memory difficulties (Elixhau-ser, Leidy, Meader, Means, & Willian, 1999; Giovagnoli, Mascheroni, &Avanzini, 1997; Hanninen et al., 1994; Hermann et al., 1995; Scogin, Stor-andt, & Lott, 1985). On the other hand, repeated experiences of memory fail-ures in everyday life may result in loss of independence, limited employmentprospects and increased anxiety (Giovagnoli et al., 1997; Hermann et al.,1995; Ownsworth & McFarland, 1999; Ponsford, Sloan, & Snow, 1995; Sohl-berg, Johansen, & Geyer, 1994).

Efficacy of the rehabilitation programme

A new everyday memory rehabilitation programme that was developedspecifically for this study was found to be effective in reducing children’severyday memory difficulties. The gains were somewhat reduced on thefollow-up, but memory difficulties had not returned to the pre-treatmentlevels. In addition, secondary gains were found in cognition and behaviour.

Our study offers further evidence of DSIT being effective in reducingeveryday memory difficulties in patients with ABI. We found that childrenand parents reported significant improvements in everyday memory. Inaddition, children made a significantly greater number of diary entries post-training. Interestingly, children’s (but not parents’) reports of reduced every-day memory deficits (CMQ) post-training were correlated with an increase indiary use (greater number of diary entries). Moreover, on pre-treatmentassessment children’s (but again not parents’) ratings of their everydaymemory skills correlated significantly with results obtained on cognitivetests; greater everyday memory difficulties were associated with worse atten-tion. Together, these results suggest that the children who participated in thisstudy may have had good insight and awareness of their memory deficits,which in turn enhanced the efficacy of DSIT. Ownsworth and McFarland(1999) also found that participants who had a basic self-awareness oftheir difficulties were more likely to use their diaries and report fewereveryday memory difficulties post-training. In addition, Cicerone et al.(2000) suggested that memory rehabilitation is most effective when

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participants are fairly independent in daily function and are actively involvedin identifying the memory problem to be treated. All participants in our studyattended regular schools, and the programme encouraged participants toidentify daily living situations in which they were likely to have difficultieswith memory as well as discuss, practise and test strategies that couldreduce these everyday memory problems. Furthermore, flexibility of the pro-gramme, small group sizes and high level of interaction are likely to haveenhanced the therapeutic relationship between the client and the instructor.This may have been as important as it is in psychotherapy where thetherapeutic relationship is one of the central mechanisms of change that ina meta-analytical study Asay and Lambert (1999) found to account forapproximately 30% of outcome variance.

It is interesting to note that when predictors of favourable response to train-ing were examined, on some measures higher cognitive scores pre-treatmentwere associated with greater gains in everyday memory. For example, betterattentional control/switching (Creature Counting, correct) and shared atten-tion (Sky Search Divided Task) were associated with greater gains in care-givers’ reports of everyday memory (PMQ). This indicates that perhaps notonly cognitive weaknesses, but also cognitive strengths may be importantto consider in cognitive rehabilitation. In this instance, it is possible that chil-dren who remained accurate on tasks that demanded attentional switching andability to divide attention between several tasks were perhaps less likely to getdistracted or make mistakes while making diary entries and thus benefitedfrom increased diary use.

Although not formally assessed in our study, another possible influence oneveryday memory ability was family dynamics. Rivara et al. (1993) foundthat stronger pre-injury child and family functioning has resulted in bettermemory outcomes one year after sustaining a TBI. While conducting ourstudy we noticed that some caregivers had everyday memory lapses them-selves. For example, they often forgot to come to appointments or to returnquestionnaires. It is possible that these parents were more likely to reportchildren experiencing difficulties with memory, resulting in the lack ofcorrelations between parental ratings of children’s everyday memory andscores obtained on tests of attention that significantly correlated with chil-dren’s rating of their own memory problems. It is also possible that children’severyday memory deficits are, in part, learned from modelling their care-givers’ behaviour (including lack of effective strategies and structure).Perhaps in future studies caregivers could be asked to complete everydaymemory questionnaires, for example the Prospective Memory Questionnaire(Hannon, Adams, Harrington, Fries-Dias, & Gibson, 1995), about themselvesto see how well their skills correlate with their children’s everyday memoryperformance. If this is found to be the case, development of a treatment pro-gramme that would involve both children and parents would be essential.

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In the current study, secondary gains were found in attention andbehaviour. Specifically, selective/focused attention (Sky Search, time andattention) and attention control (Creature Counting, correct) increased signifi-cantly post-training. Furthermore, children who had greater difficulties withattentional control pre-treatment, reported larger improvements in everydaymemory post-treatment. While it is difficult to be certain about the exactmechanism underlying these secondary cognitive gains, it is likely that theself-instruction (SIT) component of the programme played a significantrole. The SIT was originally developed to improve attentional control inpeople with schizophrenia (Meichenbaum & Goodman, 1971) and was sub-sequently found to reduce difficulties with attention in adults with TBI(Webster & Scott, 1983). What is more, we found that children with higherlevels of pre-treatment internalising behavioural problems (as reported bychildren on YSL and caregivers on CBCL) were more likely to showgreater benefits from the programme (as reported by children on the CMQ).Moreover, we found significant secondary gains only in internalising behav-iour (as reported by children on the YSL). Together these results suggest thatDSIT had a positive effect on both internalising behaviour and everydaymemory. This is consistent with findings by Ownsworth and McFarland(1999), who reported reductions in everyday memory deficits and lowerlevels of distress associated with memory problems following DSIT inadults with TBI. Alternatively, these improvements in behaviour may havebeen secondary to development of self-regulation strategies and problem-solving that has subsequently been applied by participants in different settingsand resulted in reduction of behavioural difficulties. For example, self-instructional training has been one of the core techniques that has been effec-tively used for treatment of anxiety disorders in children and adolescents(Barrett, Lowry-Webster, & Holmes, 1998; Kendall, 1994; Rapee, Wignall,Hudson, & Schniering, 2000; Rodebaugh, Holaway, & Heimberg, 2004). Inthese programmes, children are taught to reinterpret ambiguous situationsin less threatening ways, to test out the validity of these alternative interpret-ations, and to use self-reinforcement following such testing (Beck, Emery, &Greenberg, 1985). In our study children were thought to approach memorydifficulties as problems to be solved, to learn, devise and test possible sol-utions to the memory problems and utilise strategies that they find effective.Children could have generalised this approach to other problems they facedin everyday life, which could have resulted in problems being seen as lessthreatening and in turn could have reduced their anxiety.

There was evidence to suggest that the gains in everyday memory were notlost by follow-up, as the scores obtained on everyday memory questionnaireshad not returned to the pre-treatment levels. Nevertheless, problems withmemory were reported to be somewhat more noticeable than on completionof the treatment. The maintenance of the treatment gains could have been

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enhanced by provision of “booster” sessions and greater parental involvement.While qualitative information that was obtained during training and on follow-up was not analysed, it is worth mentioning that on follow-up the childrenspontaneously stated that they were paying attention to information better,and were making better use of memory strategies, such as WSTC (What areyou going to do?; Select a strategy for the task; Try out the strategy; Checkout how the strategy is working). The children indicated that they wereusing their diaries more often, and more effectively as well. For example,before the programme, one participant (MG) reportedly relied on her schoolteacher to check her diary after school each day. After the programme, sheindicated that she was doing this herself, and that she no longer needed herteacher’s assistance, demonstrating greater self-efficacy and independence.

Our study has several limitations and results should be considered prelimi-nary. It included children who presented with problems with memory in dailyliving and were interested in participation (rather than of children consecu-tively admitted to the Brain Injury Rehabilitation Unit). Thus the outcomeof the study could have been significantly influenced by a high level of motiv-ation (nevertheless, motivation was not measured). In addition, the samplesize was modest; a larger sample would allow for multiple regression analysesto be conducted to examine predictors (rather than correlates) of everydaymemory complaints and factors contributing to gaining benefits from thetraining programme. Furthermore, the assessment of cognitive skills wasfairly limited. It is possible that results obtained on other standardised cogni-tive tests that were not included in this study (such as those of working, visualand especially prospective memory) could have significant correlation withscores obtained everyday memory questionnaries. Moreover, two differenttest batteries (WISC-IV or WASI), rather than one, were used to estimatethe FSIQ. While this could have influenced selection, it is important tonotice that in our sample the lowest FSIQ score was 89, which was muchhigher than the inclusion score of 79, making it unlikely that children withbelow average IQ were included in the study. Finally, while a double baselinethat was obtained for diary entries indicated that an increase in diary use wasnot due to developmental changes or random fluctuations, a randomisedcontrolled design and double blinding would significantly increase thestrength of the evidence that the changes in everyday memory could beattributed specifically to the effects of the programme.

Overall, the results of the current study are highly relevant for clinicalwork, as difficulties with memory in everyday life represent the most frequentcognitive complaint in patients with ABI. Our findings suggest that in chil-dren with ABI everyday memory complaints are associated with difficultiesin attention/speed of information processing and internalising behaviouralproblems. On completion of the newly developed everyday memory rehabi-litation programme, significant improvements were found on subjective

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(Child Memory Questionnaire) and objective (diary entries) measures ofeveryday memory. Secondary gains were evident in attention and behaviour.Clinically, we believe that it is important to develop programmes and offerrehabilitation to patients who manifest problems with memory in everydaylife rather than restrict intervention to patients with poor scores on standar-dised memory tests. This in turn can increase psychological well-being andadaptive functioning.

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First published online 1 February 2011

APPENDIX 1

Brief description of the memory training programme

Session one: Introduction and external strategy. Aims to introduce par-ticipants to the programme and to each other and familiarise them with thediaries and training materials.Session two: Internal strategy – 1. Examines and demonstrates thebenefits of self-instruction. Teaches the WSTC techniques and discusseshow WSTC can help with memory and increase diary use in everydayactivities.Session three: Internal strategy – 2. Explores situations from participants’own lives in which self-instruction and WSTC could help with memoryproblems.Session four: Impact of attention. Teaches how attention and concen-tration could be related to everyday (especially prospective) memory problems,discusses how WSTC could help and provides prospective memory exercises.Session five: Elaboration. Enhances the children’s awareness of theimportance of attention and strategy use through case discussions of forgetfulchildren: any opportunity to use WSTC and/or diary to help their memory isto be identified.Session six: Consolidation. Revises the knowledge gained through furthercase scenarios and prospective memory tasks, examines individual gains andencourages use of diaries and internal strategies.

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