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To conduct a feasibility study to compare the effects of top-down Strategic Memory and Reasoning Training (SMART) versus information-based Brain Health Workshop (BHW, control) on gist-reasoning (ie, abstracting novel meaning from complex information), memory, executive functions, and daily function in adults with traumatic brain injury. Twenty-eight participants (of the 35 recruited), 16 men & 12 women, aged 20 to 65 years (M = 43, SD = 11.34) at chronic stages posttraumatic brain injury (2 years or longer) completed the training. Fourteen participants that received SMART and 14 participants that completed BHW were assessed both pre- and posttraining. Thirteen of the SMART trained and 11 from BHW participated in a 6-month testing. The study was a single blinded randomized control trial. Participants in both groups received a minimum of 15 hours of training over 8 weeks. The SMART group significantly improved gist-reasoning as compared to the BHW group. Benefits of the SMART extended to untrained measures of working memory and participation in functional activities. Exploratory analyses suggested potential transfer effects of SMART on memory and executive functions. The benefits of the SMART program as compared to BHW were evident at immediately posttraining and 6 months posttraining. This study provides preliminary evidence that short-term intensive training in top-down modulation of information benefits gist-reasoning and generalizes to measures of executive function and real life function at chronic stages of post-TBI.
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J Head Trauma Rehabil
Vol. 26, No. 3, pp. 224–239
Copyright c
2011 Wolters Kluwer Health |Lippincott Williams & Wilkins
Higher-Order Reasoning Training
Years After Traumatic Brain Injury
in Adults
Asha K. Vas, MS; Sandra B. Chapman, PhD; Lori G. Cook, PhD; Alan C. Elliott, MAS, MBA;
Molly Keebler, MS
Objective: To conduct a feasibility study to compare the effects of top-down Strategic Memory and Reasoning
Training (SMART) versus information-based Brain Health Workshop (BHW, control) on gist-reasoning (ie, abstract-
ing novel meaning from complex information), memory, executive functions, and daily function in adults with
traumatic brain injury. Participants: Twenty-eight participants (of the 35 recruited), 16 men & 12 women, aged 20
to 65 years (M=43, SD =11.34) at chronic stages posttraumatic brain injury (2 years or longer) completed the
training. Fourteen participants that received SMART and 14 participants that completed BHW were assessed both
pre- and posttraining. Thirteen of the SMART trained and 11 from BHW participated in a 6-month testing. Design:
The study was a single blinded randomized control trial. Participants in both groups received a minimum of 15
hours of training over 8 weeks. Results: The SMART group significantly improved gist-reasoning as compared to
the BHW group. Benefits of the SMART extended to untrained measures of working memory and participation in
functional activities. Exploratory analyses suggested potential transfer effects of SMART on memory and executive
functions. The benefits of the SMART program as compared to BHW were evident at immediately posttraining
and 6 months posttraining. Conclusion: This study provides preliminary evidence that short-term intensive training
in top-down modulation of information benefits gist-reasoning and generalizes to measures of executive function
and real life function at chronic stages of post-TBI. Keywords: adults,cognitive training,executive function,frontal lobe
function,gist,reasoning,traumatic brain injury rehabilitation
TRADITIONALLY, cognitive rehabilitation efforts
following a traumatic brain injury (TBI) have fo-
cused on a structured “drill and practice” approach to
remediate cognitive functions. Most treatment programs
aim to improve (a) a specific cognitive process (eg, at-
tention training), (b) functional tasks such as cooking
or driving, or (c) use of external aids to compensate
for memory impairments.1–8 These training protocols
have proven successful in improving general intellec-
tual functioning, memory, and mastery of targeted skills
in acute stages of recovery and continue to be ben-
eficial posttraining for short periods of time (eg, 3–6
months).9,10 However, a vast majority of survivors con-
Author Affiliation: Center for BrainHealth, The University of Texas at
Dallas, Dallas.
The authors thank the participants and their families for their interest and
enthusiasm in taking part in the study. This research was supported by the
Prothro-McDermott fund of the Dallas Foundation, Wood-Hayner-Yates TBI
Research Fund, Julie and Ed Hawes, and the Dee Wyly Research fund. The au-
thors also thank Kamini Krishnan, Michelle Kandalaft, and Nyaz Didehbani
for their help with the assessments.
Corresponding Author: Sandra B. Chapman, PhD, Center for BrainHealth,
The University of Texas at Dallas, 2200 W. Mockingbird Lane, Dallas, TX
75235 (schapman@utdallas.edu).
DOI: 10.1097/HTR.0b013e318218dd3d
tinue to present with impairments in daily functions
that necessitate higher-order cognitive skills, especially
in chronic stages of recovery (ie, 1 year or longer after
injury).11, 12 In fact, the majority of existing cognitive
treatments to remediate the sequelae of TBI occur dur-
ing the acute phase of injury, despite the evidence that
functional impairments produce lasting burden on the
individual and family.13
The paucity of cognitive training programs that mit-
igate impairments of higher-order critical thinking ap-
pears to be driven by 2 primary factors. First, only a
handful of cognitive training studies are grounded in
a theoretical framework.13 Second, few controlled trials
have been conducted to evaluate the treatment efficacy
of cognitive training programs that specifically aim to
improve higher-order skills.9,13,14 To address these limi-
tations, clinicians and theorists propose the application
of theory-driven cognitive therapies that target frontal
lobe-mediated top-down modulatory processes to im-
prove higher-order cognitive skills in TBI.15 Top-down
control processes are goal-oriented, internally driven,
voluntary (not automatic) cognitive operations that both
focus attention on task-relevant stimuli and ignore ir-
relevant distractions.13, 16, 17 Neurally, top-down mod-
ulation involves bidirectional operations of both the
Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
224
Gist-Reasoning Training 225
enhancement and suppression of neural activity in cor-
tical regions depending on the relevance of the informa-
tion to our goals.16–18 Increasingly, imaging data support
the role of prefrontal cortices in top-down modulatory
tasks.18, 19 Training top-down control processes in adults
with TBI may be beneficial in restoring and improving
cognitive function, as the frontal networks are typically
the areas most affected by a TBI.14, 15
Researchers are beginning to adopt theoretical frame-
works to guide cognitive training. For example, the goal-
management training (GMT) and goal-oriented atten-
tion self-regulation training programs were developed
based on the theory of goal neglect.20 The GMT tar-
gets the disorganization of behavior which is com-
monly seen following TBI and aims to improve goal-
directed behavior through training in discrete stages of
goal completion, including assessing a situation and di-
recting attention toward relevant goals, selecting appro-
priate goals and partitioning these into subgoals, and
monitoring progress toward the goal. Levine and col-
leagues reported that post-GMT training (brief version, 1
session), adults with TBI showed improved performance
on both trained skills and the untrained domains of
simulated real-life tasks (eg, proofreading). In a single-
case study of a postencephalitic participant who sought
to improve her cooking ability, generalization benefits
of the expanded version of GMT (8 sessions) were re-
ported on other real life situations.21 A modified ver-
sion of the GMT program (4 sessions) in healthy older
adults also yielded generalized benefits to simulated
real-life tasks and self-rated executive functions main-
tained at long-term follow-up.22 Similar to the GMT,
the GbSM training protocol involved application of at-
tention regulation strategies to participant-defined goals.
Following a 5-week goal-oriented self-regulation pro-
gram, researchers reported improved attentional func-
tions (primary outcome measures) and generalized ef-
fects to executive functions examined on standardized
neuropsychological measures of working memory, men-
tal flexibility, and self-reported improved functional task
performance.23
Another cognitive training program that adopted a
theoretical framework is the problem-solving training
(PST) developed by Rath and colleagues. This training is
based on the social problem-solving theory that refined
the construct to emphasize problem-solving in everyday
social contexts.24, 25 Specifically, the treatment program
trains social problem-solving skills in the discrete steps
of (1) problem definition and formulation (identifying
the conditions and constraints of problematic situations
and setting realistic goals), (2) generation of alternatives
(brainstorming a range of possible solutions), (3) deci-
sion making (examining potential consequences of op-
tions and selecting an optimal one, given the conditions
and constraints of the problem), and (4) solution imple-
mentation and verification (enacting solutions, moni-
toring their effectiveness, and making modifications as
necessary). The 24-session PST uses worksheets, group
discussions, and role-play through the 4 stages of the
training. Improved performances on problem-solving
measures (trained domain) were reported along with im-
proved visual memory and decreased perseverative er-
rors on the Wisconsin Card Sorting Test (a measure of
executive function).
In addition to theory-based intervention approaches
that are either specific task-based or specific impairment-
based (eg, problem-solving), researchers proposed
learning-based approaches to remediate cognitive
dysfunction.26, 27 For example, Gordon and colleagues’
Executive Plus model proposes combining principles
of top-down approaches to maximize learning so that
treatment benefits generalize across a variety of life situ-
ations. Maximizing learning specifically refers to master-
ing the prerequisite skills required to remediate impair-
ments. One example is to integrate attention training
principles with PST to attend to necessary information
to learn solve problems.4,24,25 Another example is to
combine PST with self-regulation training to facilitate
an individual’s ability to control impulses while solv-
ing a problem.27, 28 In essence, the Executive Plus model
postulates a cumulative benefit of combining different
intervention principles to maximize learning.
In addition to limited studies with theoretically moti-
vated cognitive training programs, methodological is-
sues have limited our understanding of the efficacy
of many cognitive training programs. Large-scale re-
views of cognitive training programs have identified
that the majority of studies did not include a control
group and/or employed small sample sizes or single-
subject research designs.29– 31 Moreover, outcomes of
training programs were limited to specific tasks trained
or neuropsychological tests. Specifically, reviews of ex-
isting cognitive training programs conclude that treat-
ment effectiveness often does not generalize to everyday
life.32, 33 One recently developed strategy-based train-
ing program, labeled Strategic Memory and Reasoning
Training (SMART), described later, was developed based
on the theoretical construct of “gist-reasoning” that is
relevant to everyday life tasks.34– 36
CONSTRUCT OF GIST-REASONING
One remarkable capacity of the human brain is its
adeptness in processing large amounts of information.37
To effectively process this vast amount of information,
individuals show a preference for a top-down strategy of
abstracting global meaning(s) or “gist” over a bottom-up
strategy of encoding all the details, in a process of gist-
reasoning.38, 39 Gist-reasoning is defined as the ability to
abstract gist meanings from information, which is con-
veyed in news articles, movies, and legal documents,
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226 JOURNAL OF HEAD TRAUMA REHABILITATION/MAY–JUNE 2011
to mention a few.40, 41 The ability to assimilate and
interpret generalized meanings when faced with vast
amounts of detailed information is not only an ef-
ficient cognitive function, but also has been associ-
ated with frontal lobe activation and performance on
executive function measures as well as everyday life
performance.42, 43 In other words, the propensity to en-
gage in gist-reasoning versus remembering details not
only minimizes cognitive overload of incoming stimuli,
but also assists in constructing a form of meaning that is
more robustly stored and retrieved than the composite
details.36, 38
From a theoretical perspective, these 2 forms of mem-
ory, that is, gist-based versus detail-based, purportedly
operate independently and are dissociable.38, 44 Whereas
memory for gist involves assimilating and interpreting
incoming information at an abstract level of meaning,
memory at a detail or verbatim level is represented by
the explicit facts. More recently, theorists adopted a
constructivism view and proposed that although gist
and detail are dissociable, gist representations can assist
in memory for verbatim content (ie, details). That is,
an individual with higher gist-reasoning skills may be
more strategic in encoding details than an individual
with lower gist-reasoning.44
Empirically, distinctions between memory for gist and
memory for details have proven to be clinically informa-
tive when elucidating cognitive impairments in healthy
older adults and in clinical populations. For example,
cross-sectional and longitudinal studies of cognitively
normal older adults have found gist-reasoning to be rel-
atively stable despite decline in detail memory.45 The
assumption is that older adults tend to rely on relatively
intact gist-reasoning capabilities to compensate for de-
clining episodic memory for details.46 Whereas adults
with aphasia present with relatively intact gist process-
ing ability and decreased memory for details, individuals
with right hemisphere brain damage demonstrate im-
paired gist-processing ability and relatively intact mem-
ory for details.47–50 Adults with Alzheimer’s disease ex-
perience both gist and detail deficits.51 A recent study
with adolescents with moderate to severe TBI identi-
fied impaired gist-reasoning despite intact memory for
explicitly stated details of texts.52 Preliminary evidence
suggests lowered gist-reasoning performance in adults
with TBI as compared to healthy adults.53
Three cognitive control processes considered funda-
mental to gist-reasoning include (a) strategic attention
(inhibiting less relevant information), (b) integrated rea-
soning (abstracting concepts by combining pre-existing
knowledge with relevant facts), and (c) innovation (flexi-
bly and fluently deriving multiple interpretations by in-
terpreting the information from different perspectives).
Previous research has shown that gist-reasoning and
intelligence are related.35, 36 Moreover, gist-reasoning
draws upon frontally mediated fluid intelligence do-
mains of inhibition, working memory, concept abstrac-
tion, fluency, and cognitive flexibility, all of which
engage frontally mediated top-down processes.41, 42, 54
Nonetheless, the effects of TBI on gist metrics remain
significant even after controlling for performance on
intelligence quotient measures.40 Thus, gist-reasoning
may be related to intelligence, but may also represent
a cognitive function that measures a unique ability be-
yond what is captured by standard intelligence quotient
measures. With regard to the role of memory, evidence
indicated significant contribution of working memory
to gist-reasoning over and above what is explained by
memory for explicit facts.42, 53
Additional support for the relevance of the construct
of gist-reasoning comes from neural evidence of a sig-
nificant role of frontal networks in processing gist. For
example, recent evidence found brain regions to be dif-
ferentially active during encoding of details versus gist.55
Whereas encoding of details recruited a large area in the
superior temporal gyrus in the left hemisphere and ex-
tended into the superior temporal sulcus and middle
temporal gyrus, encoding of gist was associated with
frontal lobe activation. Specifically, extensive frontal ac-
tivation was reported in the region centered over the
right precentral sulcus. Similarly, Robertson and col-
leagues found right inferior frontal activation when par-
ticipants attended to gist-related information as com-
pared to detail-related information, which activated pre-
dominantly the left anterior temporal region.56 Right
frontal activations have also been reported when elicit-
ing gist-related constructs of inferring a moral of a story
or constructing a title for a story.57, 58 In children with
chronic TBI, researchers have reported a positive cor-
relation between perfusion in right frontal regions and
more proficient gist-reasoning abilities.59
On the basis of the relevance of gist-reasoning as an
informative metric, especially in clinical populations
with frontal impairments, Chapman and colleagues34
adopted the construct to formalize and test a training
protocol, labeled SMART.36 The SMART program uti-
lizes a top-down strategy-based approach to train indi-
viduals to construct generalized meanings with no direct
emphasis on remembering explicit facts. The strategy
instruction is hierarchical, with each strategy dynami-
cally building upon previous strategies to transform the
explicitly encountered details into abstracted gist mean-
ings through reasoning and inferencing (Table 1). In
addition to the manualized content, the SMART pro-
gram encompasses application of the learned strategies
to activities relevant in daily life contexts.36, 41
Recent studies show improved gist-reasoning perfor-
mance following SMART in typically developing mid-
dle school children, in senior adults, and in adolescents
with attention deficit hyperactivity disorder.36, 41, 60, 61
Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Gist-Reasoning Training 227
TABLE 1 Strategic Memory And Reasoning Training (SMART) program
Sessions Frontal lobe function Strategy Illustration
1–3 Strategic attention
To reduce the load of incoming
details by inhibiting less relevant
information.
1. Filter Read article/information 2–3 times to
get an idea what it’ is all about.
Delete “unimportant” information.
4–5 Integration
To combine important facts to form
a higher-order abstracted meaning
by integrating the explicit content
with pre-existing knowledge to
form more global, gist-based
representations.
2. Focus/ Chunk Combine important details to
express important ideas.
Write a sentence or 2 that
synthesizes the important
information (gist concepts) in your
own words.
3. Link Link information chunks with world
knowledge to create an concise
overview. Write a summary that
conveys abstracted and novel/
new ideas.
6–8 Innovation
To derive multiple abstract
interpretations by evaluating the
information from different
perspectives.
4. Zoom Zoom out to help you see the forest
instead of just the trees (ie, think of
information in a broader context).
Zoom in to include details that
support the main ideas
9–10 5. Generalize Read other information to discover
the diverse deeper meanings and
multiple interpretations from as
many perspectives as possible.
Justify the meaning(s) from another
perspective.
11–12 Booster sessions Review all strategies Participants discuss the application
of the strategies in real life.
For example, Gamino and colleagues36 found that mid-
dle school students who had cognitive strategy instruc-
tion focused on abstracting meaning significantly im-
proved both their gist-reasoning and fact-learning abili-
ties as well as improved academic performance on state-
mandated tests (eg, Texas Assessment of Knowledge and
Skills). In contrast, students who learned only rote mem-
ory strategies failed to show gains in gist-reasoning de-
spite gains in fact-learning. Similarly, Anand and col-
leagues found significant improvement in gist-reasoning
performance after just 8 hours of gist-reasoning train-
ing in older adults. Moreover, significant transfer effects
were found on executive functions, including cognitive
switching, concept abstraction, and verbal fluency.
Whereas limited research has demonstrated benefits
of top-down training in adults with TBI, it is not known
if the top-down cognitive control training of SMART
would be beneficial in this population, especially in
chronic stages of recovery. Therefore, a feasibility study
was designed with specific aims as delineated below.
AIMS OF THE STUDY
The present feasibility study examined the ability to
improve gist-reasoning in chronic stage TBI by com-
paring an experimental strategy-based SMART program
versus an information-based Brain Health Workshop
(BHW) control program (described in the Methods sec-
tion) in an equivalent amount of training, immediately
post- and at 6 months posttraining. The secondary aim
was to explore whether the effects of the SMART pro-
gram versus the control program generalized to un-
trained areas of memory, executive function, and self-
ratings on daily function measures, immediately post-
and at 6 months posttraining. It was postulated that a
top-down SMART approach to learning would enhance
gist-reasoning abilities. Moreover, we predicted that ben-
efits of the SMART program would also generalize to
untrained domains of memory, executive function, and
daily function ratings. We also predicted that these gains
would be sustained at 6-month follow-up testing.
METHODS
Participants
Thirty-five community dwelling individuals with TBI
between the ages of 20 and 65 years at testing in chronic
stages of recovery, at least 1-year postinjury participated
in the study. The cause of TBI in 26 of the 35 participants
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www.headtraumarehab.com
228 JOURNAL OF HEAD TRAUMA REHABILITATION/MAY–JUNE 2011
was due to a motor vehicle accident (25 were involved in
car accidents and 1 motorcycle accident), 4 were sports-
related, 4 were work-related (eg, object hitting the head),
and one was due to assault. Twenty-eight of the 35 indi-
viduals completed the training. As indicated in the Con-
solidated Standards of Reporting Trials (CONSORT)
flow diagram-Figure 1, the reasons for dropout are con-
sidered random and were evenly divided between the
2 groups. Thus, the study results are based on the per-
formance of those that completed the training program.
Nine of the 28 participants were gainfully employed out-
side their homes, working between 15 and 30 hours a
week. Ten of the rest of the 19 participants were engaged
in other productive activities including volunteering at
churches, food banks, and assisted living facilities on a
regular basis. The remaining 9 participants were living
alone in the community and were not gainfully em-
ployed or involved in volunteer activities. The majority
(23 of 28) of the participants sustained their injuries
over 15 years ago, and hence there was limited access
to medical records that provided reports of the severity
of the TBI. One participant had a documented GCS
score of 7 (ie, severe), 5 participants had the severity
of TBI documented as “severe” with no GCS scores,
2 participants had the severity documented as “mild”
and the initial severity was unavailable for the rest of
the participants. Therefore, the period of retrospective
posttraumatic amnesia (PTA), a commonly used predic-
tor of functional outcomes following a TBI, was used
as an estimate of early injury severity. We acknowledge
the limitation in using retrospective self-reported PTA,
especially since some of the participants were injured at
an early age and it was not possible to verify PTA with
medical records. Although the accuracy of a retrospec-
tive self-reported PTA is equivocal, similar methods for
examining PTA as a rough index of early injury severity
have been utilized in previous chronic-stage studies
when early medical information was not available.62- 64
The period of PTA was obtained during the initial testing
by asking the participants to estimate how long it was be-
tween their injury and the time when he/she felt like they
started remembering things continuously. Participants
Figure 1. CONSORT flow diagram. BHW indicates Brain Health Workshop; SMART, Strategic Memory and Reasoning
Training.
Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Gist-Reasoning Training 229
were told not to tell the time when they thought their
memory was back, but rather when they started remem-
bering day-to-day events in a consistent way.
In addition, since early injury severity has been ques-
tioned as a reliable predictor of severity of deficits years
after sustaining a TBI, we adapted a methodology to
establish current level of disability. Whereas a current
level of disability cannot be directly or solely attributed
to the earlier injury, it is relevant to documenting sta-
tus at time of training. Specifically, we used 2 valid and
reliable self-reported functional measures, the Glasgow
Outcome Scale-Extended (GOS-E) and the Functional
Status Examination (FSE), to characterize current sever-
ity of functional impairments. The GOS-E is a gross
outcome measure that tracks degree of functional recov-
ery with broad functional categories of cognition, mood,
and behavior on an 8-point scale.65 The possible score
ranges from 2 to 8, with 8 indicating good recovery and
2 indicating a vegetative state. A score of 5 or 6 character-
izes moderate functional recovery. The FSE offers some
advantages over GOS-E as it provides a more detailed
description of the functional deficits and the amount of
assistance needed to accomplish the function. The self-
reported FSE tests 10 functional categories including
personal care, mobility/ambulation, travel, work and/or
school, leisure and recreation, home management, social
integration, cognitive and behavioral competency, stan-
dard of living, and financial independence.66 Ascoreof
10 signifies no impairment, 11 to 20 as mild impairment,
21 to 30 as moderate impairment, and a score above 30 is
indicative of severe impairment. Participants with mod-
erate functional impairments on the measures GOS-E
(range =5–6) and FSE (range =21–30) were included
in the study. These 2 functional measures were also
included as pre-/posttraining comparison measures of
daily function, as they are considered valid predictors of
long-term functional outcome in adults with TBI.67– 69
Only native English speakers with at least a high
school education who scored a minimum of ninth grade
equivalency on vocabulary and comprehension on the
Nelson-Denny reading test and had a minimum pre-
morbid estimate of verbal intellectual functioning of
90 as measured by the North American Adult Reading
Test were included in the study.70, 71 Participants were
not provided with any transport to attend the sessions;
hence, all participants were either independent drivers,
used public transport, or had other means to attend the
sessions.
Exclusion criteria included pre-TBI histories of stroke,
learning disability, communication disorder, substance
abuse, or major psychiatric disorder. The current study
did not include participants with current depression sta-
tus, as determined by the Beck Depression Inventory
(BDI-II), such that participants with a BDI score above
9 were not included in the study.72 In addition, partic-
ipants who were receiving cognitive treatment(s) at the
time of the assessment were excluded from the study.
Three participants were from the University of Texas
Southwestern Medical Center Traumatic Brain Injury
Model System, 2 were referred by a local neuropsychol-
ogy clinic, and the remaining participants were recruited
from local brain injury support groups. Informed con-
sent obtained from all participants was in approval and
accordance with the guidelines of the institutional re-
view boards of the University of Texas at Dallas and
University of Texas Southwestern.
Procedure
The current study was a single-blinded random-
ized control trial, where participants were randomly
assigned to one of the 2 protocols: (a) top-down
SMART(experimental group) or (b) information-based
BHW (control group).73 Participants were informed that
the goal of the study was to compare the benefits of 2
training programs that could be beneficial to adults with
TBI. In addition, they were told that they would be ran-
domly assigned to one of the 2 training programs after
they agreed to participate. Measurement outcomes of
both protocols included the same battery of experimen-
tal and standardized cognitive tests as well as functional
measures. The examiners involved in testing, scoring,
and data analyses were blinded to the group and time
(ie, pre-, immediately post-, and at 6 month posttraining
status). Training was initiated within 3 weeks of testing
the participants. Posttesting took place within 3 weeks of
completion of the training program. Six-month follow-
up testing took place 6 to 7 months after the training
sessions were completed.
Measures
Measures of gist-reasoning, memory, executive func-
tion, and day-to-day function were included in the
study. The primary outcome measure of gist-reasoning
was examined with the Test of Strategic Learning
(TOSL)(S.ChapmanJ.Hart,H.Levin,L.Cook,J.
Gamino, unpublished data, 2009). The TOSL measure
has demonstrated sensitivity in examining gist-reasoning
skills in clinical populations where higher-order cog-
nitive functioning is compromised, including adults
with stroke, adults with mild cognitive impairment
or Alzheimer’s disease, and children and adults with
TBI.47,51–53 The TOSL measure consists of 3 texts, de-
signed to examine how one understands and constructs
generalized/gist meanings from connected language.
The 3 texts vary in length (from 291 to 575 words)
and complexity. For each of the texts, the participant
is asked to provide a summary or a shortened version of
the original text that focuses on the general overview of
what the text is about and does not include all of the
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www.headtraumarehab.com
230 JOURNAL OF HEAD TRAUMA REHABILITATION/MAY–JUNE 2011
details. Following these instructions, the examiner reads
each text aloud, and participants are given a copy of
the text to follow along. After the examiner completes
reading the text, the participant’s copy is taken away so
that the participant does not have the option to refer
to the original text while providing his or her summary.
Participants’ summary productions are audio-recorded
and later transcribed for scoring.
The TOSL measure has a manualized objective scor-
ing system wherein the summary productions conveying
abstracted gist meanings received a higher score than
those that focused on the stated details of the text.
Each gist meaning conveyed by the individual receives
1 point. A total score (composite score) of 37 points is
possible for the 3 summaries of the 3 texts. Two trained
examiners, blinded to the participants’ group status and
time of testing (pre- vs immediately post- vs 6-month
posttraining), independently scored the 3 summaries for
inclusion of gist-based meanings. Interrater reliability of
scores assessed on intraclass correlation coefficients in
both groups combined for gist-reasoning performance
was over 90% (Cronbach αrange =0.92–0.98, confi-
dence interval =0.78–0.98). The same measures were
used at immediate post- and 6-months posttesting.
Two measures were administered to examine memory.
Memory for details of the 3 TOSL texts (that were used
to examine gist-reasoning) was examined by means of
the “memory for details” recall measure (S. Chapman,
J. Hart, H. Levin, L. Cook, J. Gamino, unpublished
data, 2009). The “memory for details” measure includes
probes that test memory for details from the texts con-
sidered important for understanding the key ideas of
the texts. The probes followed summarization of each
text. Each text has 8 probe questions, for a total of 24
probes for all the 3 texts combined. Responses to each
memory for detail probe receives a score of 2, 1, or 0
points depending upon accuracy and completeness of
the response, yielding a composite score of 48 points for
all 3 texts. Memory was also examined by means of the
Digit Span Forward subtest from the Wechsler Adult
Intelligence Scale III.74, 75
Executive function measures included 2 measures of
working memory, and single measures of inhibition,
nonverbal reasoning, cognitive flexibility, and verbal flu-
ency. The 2 measures of working memory included the
modified version of the Daneman and Carpenter work-
ing memory Listening span task and the Letter Number-
Sequence working memory span task from the Wechsler
Adult Intelligence Scale III. In this listening span work-
ing memory test, participants listen to a set of unrelated
sentences and recall the final word of each sentence
in the set after listening to the whole sentence-set.76
Participants are presented with increasingly longer sets
of sentences, and working memory span was determined
by the maximum number of sentences the participants
could listen to while maintaining the recall of at least
two-thirds of the sentence-final words. In the Letter
Number-Sequence working memory task, the examinee
is read a combination of numbers and letters and is
asked to recall all the numbers first in ascending order
and then the letters in alphabetical order.74 Inhibition
was examined with the Delis-Kaplan Executive Function
System (D-KEFS ) Color-Word Interference task, specif-
ically the number of errors made on the inhibition (task
3) & inhibition/switching (task 4) conditions.77 The D-
KEFS Color-Word interference test measures the ability
to inhibit an overlearned verbal response (ie, reading
the printed words) to generate the conflicting response
of naming the dissonant ink colors in which the words
are printed. Nonverbal reasoning was examined on the
Matrix-Reasoning task from the Wechsler Adult Intel-
ligence Scale III.74 This test is composed of 4 types of
nonverbal reasoning tasks: pattern completion, classi-
fication, analogy, and serial reasoning. The participant
chooses 1 of the 5 response options to complete a matrix.
Cognitive flexibility was measured on the Trail Making
Test-Part B for adults.78 This test requires the participant
to connect 25 circles of numbers and letters in an alter-
nating pattern (1-A-2-B-3-C, etc) in as little time as pos-
sible. Verbal fluency was measured on the Controlled
Oral Word Association Test that requires the participant
to generate as many words as possible that begin with a
specific letter in a specific amount of time.79 These ex-
ecutive function measures were used at pre-, immediate
post-, and 6-months posttraining.
Measures of GOS-E, FSE, and Community Integra-
tion Questionnaire (CIQ) were administered to mea-
sure daily function at pre-, immediate post-, and 6-
month posttraining. Descriptions of GOS-E and FSE
are provided in the previous section that characterized
participant functional status at initial testing. The self-
reported CIQ measure provides a general overview of
an individual’s functioning based on responses to 15
questions related to participation in activities at home,
social, and education or vocation settings.80 The score
ranges from 0 to 29, with increasing scores indicating
improved level of integration in the community. Sev-
eral studies have established reliability and validity of
the CIQ measures.81–83
Training protocols
The training protocols included the experimental
SMART program and the control BHW protocol. Both
groups were controlled for the number of contact hours
with the clinicians, group interactions within group
members, and the remuneration for participation in the
study. Both SMART and BHW programs offered a to-
tal of 18 hours of training during 12 group sessions (1.5
hours each session) conducted over 8 weeks. The first 15
hours of training over 10 sessions were conducted in the
first 5 weeks (ie, 2 sessions per week). The final 3 hours of
Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Gist-Reasoning Training 231
training, over 2 booster sessions, took place at spaced in-
tervals over the next 3 weeks (ie, session 11 during week-6
and session 12 in the eighth-week). Two trained clini-
cians (a speech pathologist and an occupational thera-
pist) who had experience in TBI rehabilitation led each
group. Each group consisted of 4 to 5 participants.
Group sessions were chosen in favor of individual
sessions, as we anticipated that group discussions in
SMART and BHW could potentially reinforce partic-
ipants practice in incorporating the strategies or relating
brain health information to issues in their lives. Com-
parable number of group members in both SMART and
BHW groups controlled for the amount of social bond-
ing, which is considered therapeutic. To ensure adher-
ence to the program, the facilitators stressed the impor-
tance of attending every session and diligence in com-
pletion of homework assignments during recruitment.
Specifically, participants were also told that their contri-
bution to this specific study and the science of cognitive
rehabilitation in general greatly relied on these 2 factors
(ie, attendance and homework assignments).
Sessions were both didactic and interactive in nature.
Training materials, including power point handouts and
preselected reading material, were given to the partici-
pants in both SMART and BHW in a binder to take
home and to be brought back for the following session.
Participants were allowed to keep the binders after com-
pletion of the training program. All of the participants
received $10 per visit (including testing and treatment)
during their participation in the study. It is interesting
to note that individuals in both groups seemed to enjoy
participating in the training. The SMART group partici-
pants discussed the benefits of the strategies in their ev-
eryday life and the BHW expressed benefits from learn-
ing about the brain and the effects of a TBI on the brain.
Strategic memory and reasoning training
(experimental group)
The SMART strategies were introduced to the group
in a power point format with a description of the strategy
(Table 1). The description included explaining the role
of frontal lobes in mediating these strategies and the rel-
evance of these strategies to derive gist. Preselected ma-
terials of varying lengths, including newspaper articles
and stories, were used to illustrate the strategies. More
importantly, the application of these strategies in their
daily life was emphasized. For example, to illustrate the
strategy of “inhibition,” discussions of real-life examples
included ignoring less relevant steps during event plan-
ning or ignoring distracting information when following
a lecture and so on.
The strategies were introduced in a sequential
manner (Table 1). Mastery of individual strategies was
not necessary to move on to the next level, as strategies
were continually reinforced at each stage of the pro-
gram. Following each session, participants were given
preselected homework assignments that predominantly
utilized written material. The written material included
articles from local newspapers, magazines, and lectures.
Along with these preselected assignments, homework
also included that participants identify or select specific
life activities in which SMART strategies could be
incorporated.
One specific real life example of writing a resume
using the SMART approach was illustrated by one par-
ticipant. The first step of strategic attention (ie, strat-
egy of filter) involved deleting information that would
not be relevant to include in the individual’s resume.
In addition, the individual had to selectively identify
the most important information related to his/her own
skills and strengths. The second step of integration (ie,
strategies of focus and link) involved categorizing the
individual’s skills and strengths into academic accom-
plishments, leadership qualities, professional or personal
characteristics, and work experience including volunteer
work that related to the job requirements. These cate-
gories were then supported with relevant details to help
the employer/interviewer capture the breadth and depth
of that particular category. The third step of innovation
(ie, strategies of zoom and generalize) involved summa-
rizing the qualifications and abilities at a higher/broader
level, into 2 or 3 succinct statements to provide the re-
sume “objective” statement. Innovation also involved
flexibility in preparing the resume in multiple formats
and revising the objectives statements to adapt to the
different employers needs and job requirements. Appli-
cation of SMART strategies to other daily life tasks such
as planning an event, learning from a lecture or discus-
sion of a movie was also discussed.
Brain health workshop (control group)
The control group was conducted using the BHW
protocol that has been previously used as a control-
training program for experimental cognitive training
at the Rotman Institute, Toronto, and University of
California, Berkeley.73 Similar to SMART, the BHW
is a manualized program. However, rather than being
strategy-based, the BHW is information-based, covering
predetermined topics on brain anatomy, brain function-
ing, general brain health, effects of lifestyles on brain
health such as different diets and exercises, and cognitive
changes following a TBI (Table 2). During each session,
clinicians presented the assigned topics in a power point
format. Participants were given the power point hand-
outs in their binders to follow along. Group discussions
provided clarifications and further explanations of the
topics. At the end of each session, participants were also
given take-home reading assignments on related topics
that were discussed in the following sessions.
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232 JOURNAL OF HEAD TRAUMA REHABILITATION/MAY–JUNE 2011
TABLE 2 Brain Health Workshop
Sessions Topics
1–2 Introduction to brain anatomy
Different lobes of the brain
Functions of each lobe
Comparison and differentiation between a human brain and a computer.
3–4 Functions of the brain
Cognition including memory, attention, problem solving, judgment, language, and emotion
Physical abilities including movements
Sensory functions including vision, hearing, smell, and taste
Effects of traumatic brain injury on brain functions
5–6 Neuroplasticity
Structure of neurons
Neurogenesis
Procedures/techniques to measure brain function
Behavioral testing
Observations
Functional Brain Imaging techniques including ERP, fMRI/PET, and MEG
7–10 Effects of lifestyles on brain function
Sleep
Diet
Physical Activity
Stress
Emotions
11–12 Booster sessions
Review material covered in sessions 1–10
DATA ANALYSES
Three analyses were conducted in the current study.
First, comparability between SMART and BHW groups
at pretraining was examined using 2-sample Student t
tests. Specifically, comparability was examined on par-
ticipant characterization measures, gist-reasoning per-
formance, memory, executive function, and functional
rating scales. Second, a repeated measures analysis of
variance (ANOVA) examined the time by group inter-
action for gist-reasoning, memory, executive function,
and functional rating scales. In the presence of an inter-
action, pairwise comparisons were examined with Bon-
ferroni correction, where P-values .02 or less for any
pairwise comparison were considered significant. Third,
since this is a feasibility study, when measures failed
to show a time by group interaction, we compared the
main effects (means) across the 2 groups using the main
effects F-tests to determine whether observed group dif-
ferences might indicate promising hypotheses for future
(or expanded) research. Analyses were performed using
SPSS version 17.0 (SPSS Inc, Chicago, Illinois).84
RESULTS
All participants received a minimum of 15 hours
of training (ie, minimum of 10 sessions). At baseline,
the ttest analysis revealed comparability between the
SMART and BHW groups on participant characteriza-
tion measures of age at testing, age at injury, years since
injury, educational level, estimate of premorbid verbal
intellectual function (measured on the North Ameri-
can Adult Reading Test), and level of functional impair-
ment as measured on GOS-E and FSE (Table 3). Fur-
thermore, both groups were comparable in processing
speed, as measured on the D-KEFS Color-Word Inter-
ference task conditions 1 (color naming) and 2 (word
reading). Hence, these variables were not included for
further inferential analysis.
Interaction effects
Results indicated significant time by group interac-
tion effects on measures of gist-reasoning, one measure
of working memory (listening span task), and the CIQ.
Gist-reasoning performance at pretraining was compara-
ble between SMART and BHW groups, (t26 =0.33, P
=.74 ns). Qualitatively, summaries on the TOSL (mea-
sure of gist-reasoning) at pretraining consisted predom-
inantly of statements from the original text that were
directly tied to the explicit content. At posttraining, the
majority (12 of 14 at immediate posttesting and 11 of 13
at 6-months posttesting) of the self-generated summaries
in the SMART group conveyed abstracted meanings that
were not stated in the original text. Repeated measures
ANOVA indicated significant group by time interaction
for gist-reasoning, F2,48 =3.66 P=.03 (Table 4). Pairwise
comparisons indicated that the SMART group made
Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Gist-Reasoning Training 233
TABLE 3 Demographic and clinical features of SMART (n =14) and BHW (n =14)
Variables Mean SD Range 95% CI
t
26
Current age
SMART 39.0 14.44 20–61 30.66–47.33 1.8 ns
BHW 47.0 8.24 36–62 42.68–51.32
Age at injury
SMART 22.14 15.75 3–53 13.04–31.24 1.7 ns
BHW 30.78 10.93 11–52 24.47–37.09
Years since injury
SMART 16.71 12.06 2–38 9.75–23.67 0.94 ns
BHW 16.35 13.22 2–44 8.72–23.99
Years of education
SMART 15.78 2.11 12–18 14.56–17.00 0.09 ns
BHW 15.71 1.81 12–18 14.66–16.76
NAART
SMART 115.39 8.44 98.9–126.2 110.5–120.2 0.07 ns
BHW 115.17 7.32 103.1–126.2 110.9–119.4 0.07 ns
ND reading
SMART 14.81 3.14 9.1–18.5 12.5–17.05 0.02 ns
BHW 14.77 2.95 9.4–18.4 12.3–17.24
PTA weeks
SMART 2.17 1.73 0.5–6 1.17–3.18 0.42 ns
BHW 2.46 1.82 0.5–6 1.41–3.51
GOS-E
SMART 5.42 0.51 5–6 5.13–5.72 0.29 ns
BHW 5.50 0.75 5–6 5.06–5.93
FSE
SMART 23.9 3.51 21–28 21.17–23.77 0.89 ns
BHW 25.0 3.26 22–30 23.48–26.23
Note.
The SMART consisted of 9 men and 5 women. The BHW group consisted of 7 men and 7 women.
Abbreviations: FSE, Functional Status Examination; GOS-E, Glasgow Outcome Scale-Extended; NAART, North American Adult Reading
Test; ND, Nelson-Denny Reading test (including vocabulary and comprehension); Ns, Group differences were not significant; PTA, Post
Traumatic Amnesia; SD, standard deviation.
TABLE 4 Significant time ×group interactions with pair wise comparisons (Bonferroni
adjusted)
6 month
Pretraining, Posttraining, Posttraining, Analysis of
Variable Group
M
(SD)
M
(SD)
M
(SD) Variance
Gist SMART 14 (4.89) 19.76 (4.76) 21.15 (6.40)
F
2,48 =3.66,
P
=.03
BHW 12.69 (5.45) 13.69 (3.09) 14.46 (4.11)
P
=.74 ns
P
=.007
P
=.004
WM(LS) SMART 2.76 (0.59) 4.23 (0.83) 4.96 (0.92)
F
2,44 =14.57,
P
<.001
BHW 2.36 (0.67) 2.59 (0.97) 2.7 (0.68)
P
=.23 ns
P
=.005
P
=.0001
CIQ -CS SMART 15.19 (4.33) 18.73 (3.02) 19.88 (3.50)
F
2,46 =4.90,
P
=.02
BHW 15.87 (4.81) 16.45 (4.77) 15.83 (4.33)
P
=.33 ns
P
=.38 ns
P
=.01
CIQ-SI SMART 6.61 (1.85) 8.07 (2.01) 8.96 (2.02)
F
2,46 =4.23,
P
=.02
BHW 6.90 (2.16) 7.27 (2.28) 6.81 (1.66)
P
=.43 ns
P
=.16 ns
P
=.01
Abbreviations: CIQ-CS, community integration questionnaire-composite score; CIQ-SI, community integration questionnaire-social
integration sub-scale;
M
, mean, ns, group differences were not significant; SD, standard deviation; WM (LS), working memory-listening
span.
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234 JOURNAL OF HEAD TRAUMA REHABILITATION/MAY–JUNE 2011
significant gains immediately posttraining (t26 =2.91,
P=.007) and at 6 months posttraining (t24 =3.17, P=
.004) when compared to pretraining level. However, the
BHW did not show significant changes in gist-reasoning
either at posttesting (t26 =0.775, P=.44), or at 6-month
follow-up (t24 =0.65, P=.52) when compared to the
pretraining level (Table 4).
At the pretraining level, both SMART and BHW
groups were comparable on the working memory mea-
sure of listening span (t26 =1.22, P=.23 ns). At post-
training, a repeated measures ANOVA indicated signifi-
cant group by time interaction for the working memory
measure of listening span, F2,44 =14.57, P<. 001.
Listening span capacity in the SMART group, both
immediately posttraining and at 6 months posttraining
was significantly higher than pretraining score (Table 4).
The BHW did not show any significant changes in the
listening span task at either immediate posttraining or
at 6 months posttraining.
The ttest analyses found that both SMART and BHW
groups were comparable at pretraining on the func-
tional rating scales of CIQ (t26 =0.99, P=.33 ns).
At posttraining, repeated measures ANOVA indicated
significant group by time interaction on the CIQ (com-
posite) rating scale, F2,46 =4.90, P=.02. The CIQ
(composite) score in the SMART group at 6 months
posttraining was significantly higher than the pretraining
score (Table 4). Furthermore, a significant time by group
interaction was indicated for the CIQ subscale of social-
integration, F2,46 =4.23, P=.02. The social-integration
rating scale at 6 months posttraining was significantly
higher than pretraining score (Table 3). No significant
changes were noticed for the home-integration or pro-
ductivity subscales of the CIQ. The BHW group did not
show any significant changes over time on any of the
functional rating scales.
Exploratory analyses
Exploratory between-subjects analyses examined the
main effects of the groups. In terms of memory, at the
pretraining level, both SMART and BHW groups were
comparable on the measures of memory for text details
(t26 =0.45, P=.65 ns) and digits forward (t26 =0.62, P
=.53 ns). Significant main effects in the SMART group
were found on memory for text details, F1,22 =6.10,
P=.02 (M[SD]: pretraining =33.5 [5.6], immedi-
ately posttraining =41.2 [5.6], 6-month posttraining =
40.08 [3.2]). No significant changes were noticed in ei-
ther group at immediate post- and 6-month posttraining
period on the memory measure of digits forward (WAIS-
III).
With regard to executive functions, both SMART
and BHW groups were comparable at pretraining on
the measures of inhibition measured on color-word in-
terference D-KEFS tasks 3 and 4 (t25 =0.39, P=.69
ns), working memory on the Letter-Number Sequenc-
ing task (t26 =0.05, P=.95 ns), nonverbal reasoning
on the Matrix Reasoning measure (t26 =1.23, P=.22
ns), verbal fluency measured on Controlled Oral Word
Association Test (t26 =0.98, P=.33 ns), and cognitive
flexibility measured on Trails B (t26 =1.16, P=.25 ns).
Significant main effects were found in the SMART
group on 3 executive function measures. The 3 mea-
sures included (a) inhibition F1,21 =7.63, P=
.01, where lower mean indicates fewer errors on
the color-word interference task (M[SD]: pretrain-
ing =8 [5.01], immediately posttraining =3.7
[3.09], 6-month posttraining 2.08 [1.7]), (b)nonver-
bal reasoning (on Matrix Reasoning measure) F1,22 =
14.06, P=.001 (pretraining =12.21 [2.9], imme-
diately posttraining 14 [2.82], 6-month posttraining
=14.62 [2.69]), and (c) cognitive flexibility F1,22 =
7.17, P=.01, where lower mean indicates less time
(in seconds) taken to successfully complete the Trails-
B task (pretraining =70.57 [32.93], immediately post-
training =68.36 [56.01], 6-month posttraining =59.08
[24.18]). No significant main effects were evident on the
functional scales of GOS-E and FSE.
DISCUSSION
The current study presented a theoretical construct
and empirical evidence for a strategy-based approach to
promote gist-reasoning in adults with TBI. The construct
of gist-reasoning elucidates an ecologically valid func-
tion of abstracting meaning from information in light of
(a) characterizing abstraction skills, and (b) as a method-
ological framework to improve abstraction skills. The 3-
top-down cognitive control processes of strategic atten-
tion, integration, and innovation in gist-reasoning rep-
resents the core components around which the strategy-
based SMART program was developed.
Empirically, 3 major findings emerged from the cur-
rent study that examined the effects of strategy-based
SMART versus information-based BHW training pro-
tocols in adults with TBI at chronic stages of recov-
ery. First, our findings revealed that 15 to 18 hours
of SMART enhanced gist-reasoning in adults with TBI.
Second, the effects of SMART generalized to untrained
domains such as on the working memory measure of
listening span and ratings of increased participation in
daily activities. Third, there appeared to be sustained
benefit (6 months posttraining) of SMART as compared
to the control group (BHW).
Similar to the results in the current study, improve-
ment in gist-reasoning following the SMART program
were also reported in typically developing middle school
students and in cognitively normal senior adults.36, 41
The consistent findings across studies indicate both
Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Gist-Reasoning Training 235
specific and generalized effects of a top-down oriented
strategic approach to learning, especially for complex/
lengthy information, in both cognitively impaired and
healthy adults.
Another promising finding of this study was the gen-
eralized effects of SMART training to improved per-
formance on measures of executive function, especially
that of the working memory listening span task that
elicited the person to recall the last word of an increasing
number of sentences (2–7 sentences). One possible ex-
planation for enhanced gist-reasoning affecting working
memory listening span is that the participants adopted
gist-based (higher-level) strategies to connect meaning
between the words to be remembered (eg, forming
associations, or forming a new sentence or visual im-
agery) that helped with effective recall. One might also
argue that improved working memory, either with the
help of strategies of “filter” or “chunk” may have led
to improved gist-reasoning performance. The present
findings do not inform whether both skills, that is,
gist-reasoning and working memory span, improve inde-
pendently or are interdependent. Future studies should
help elucidate this distinction of the benefits of the
SMART program. In either case, we speculate a support-
ive dynamic relation between working memory and gist-
reasoning. A supportive relation between working mem-
ory and gist-reasoning (examined on summary produc-
tion tasks) has also been reported in previous studies.40
Moreover, previous evidence has suggested that the dy-
namic nature of working memory may be more relevant
to gist reasoning than straightforward memory. Specifi-
cally, a significant contribution of working memory to
gist-reasoning over and above what is explained by mem-
ory for explicit facts has been reported in adolescent TBI
studies.42
Generalization effects following the SMART program
have previously been reported both in typically de-
veloping middle school adolescents and in cognitively
normal senior adults.36, 41 Following SMART, normally
developing middle schoolers trained in gist-reasoning
showed significant improvements in their academic per-
formance on state-mandated critical thinking tests post-
SMART. Similar benefits of top-down approaches to
teaching abstract principles versus use of concrete ex-
amples in content areas such as math have also been
reported.85 Similarly, following SMART, senior adults
improved on untrained measures of cognitive switch-
ing, concept abstraction, and verbal fluency.
Generalization benefits have also been observed on
cognitive measures following theory-based cognitive
training programs such as the GMT, goal-oriented atten-
tion self-regulation, and PST that involved application
of strategies to a preset goal or a predetermined problem
scenario, respectively.21, 23, 25 These training programs
were at the forefront in adopting theoretical frameworks
to cognitive training programs. The SMART program
broadens the scope of such theoretical strategy-based
approaches to remediate executive control deficits. The
top-down SMART approach uniquely contributes to
cognitive remediation paradigms by training adults with
TBI to be strategic thinkers. Specifically, the program
distinguishes from existing strategy-based approaches in
2ways.(a) Whereas existing approaches apply strategies
to solve or accomplish a preset goal or a predetermined
problem, participants in SMART program were trained
to apply strategies across domains during training ses-
sions. For example, during the SMART program, par-
ticipants applied the strategy of “filter” during conver-
sations, where participants ignored less relevant details
while conveying an idea, or selectively deleted less rele-
vant steps to plan an event, and so on. (b) In addition,
the intensive SMART program focuses on homework
assignments to ensure carryover of strategies beyond
training sessions. The discussions of homework assign-
ments in the groups provided therapeutic milieu to mo-
tivate, problem-solve, and innovate ways to efficiently
approach a real life task. In essence, SMART strategies
were new learning tools to repair and strengthen im-
paired higher-order cognitive skills following a TBI. Fur-
thermore, the present study is one of the first studies to
examine long-term benefits of a theory-backed training
program.
In addition to improved performance on execu-
tive function measures, the SMART group participants
made significant gains on measures of daily function.
Improved self-rating on the CIQ measure (composite
score), especially at the 6-month follow-up testing (and
not at immediate posttraining) may indicate that a long-
term sustained effort of implementing the strategies may
lead to improved participation in day-to-day tasks. Sig-
nificantly increased ratings on the social integration sub-
scale of CIQ were not due solely to the social interac-
tions with other group participants, since the BHW con-
trol group had similar social interactions and yet failed
to show increased scores at either immediate posttesting
or at 6-months posttesting. Improved social integration
in the SMART group could be secondary to improved
self-regulatory executive functions, resulting in effective
communication abilities such as not dwelling on less
relevant details, or improved life skills in terms of plan-
ning and orchestrating tasks involved in execution of
a family event, or restarting or developing new leisure
interests (eg, golf, reading novels, and church-related
activities).
The exploratory analyses results elucidated the gen-
eralizable potential of the SMART program on mem-
ory function and the executive functions of inhibition
(on Color-Word interference tasks), nonverbal reason-
ing (on the Matrix Reasoning task), and cognitive flexi-
bility (measured on trails B). The main effect of SMART
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236 JOURNAL OF HEAD TRAUMA REHABILITATION/MAY–JUNE 2011
on memory for details provided preliminary support for
the notion that improved gist-reasoning may enhance
an individual’s ability to recall facts from texts, which
is congruent with another recent SMART study in ado-
lescents. Gamino and colleagues36 showed that typically
developing middle school students who were trained to
abstract meaning also showed significant gains in abil-
ity to recall specific information from texts. In contrast,
middle schoolers trained in rote memorization skills did
not improve on gist performance. Although the current
study did not compare the effects of bottom-up straight-
forward rote memorization training versus top-down
processing, we anticipate that top-down modulation of
information has a positive impact on bottom-up pro-
cesses such as recall of details. Specifically, we propose
that clustering ideas into more abstract concepts serves
to encode details at a deeper level for learning and
memory retention. Clearly, the relation between top-
down and bottom-up processes is not typically bidi-
rectional. That is, improvement in top-down processes
has the potential to strengthen bottom-up processes, yet
strengthened bottom-up processes may not necessarily
improve top-down functions.13 Theoretically, this uni-
directional benefit of top-down processes reflects the
view of Reyna and Brainerd’s “fuzzy-trace” theory, that
gist memory can in fact improve (shape) memory for
verbatim details.38
In addition, main effects on measures of executive
functions of inhibition, nonverbal reasoning (on Matrix
Reasoning task), and cognitive flexibility (on Trails B)
suggest preliminary trends for the potential of SMART
to transfer to other untrained domains. With regard to
improving inhibition, the strategy of “filtering” ideas
may have helped override the automatic responses on
the Color-Word interference task (used as measure of
inhibition), or the “zoom out and zoom-in” strategy
may have assisted with the Matrix Reasoning task that
requires the participant to identify a missing detail of a
larger pattern. Whereas we cautiously interpret the main
effects of SMART on these 3 executive function mea-
sures, the evidence of similar transfer effects in studies
of older adults reinforces the possibility that the find-
ings may be upheld in future studies of TBI in adults.
Nonetheless, we acknowledge that the failure to find
significant group by time interaction on these measures
may be due to small sample size, individual variation,
or need for longer training period in some individuals
to achieve more widespread effects. Future studies with
larger sample sizes would help address these concerns.
Limitations and future implications
The current findings, while promising, must be inter-
preted cautiously, as they require further validation to
address at least 3 major limitations. First, we recognize
that the participants in the present study were recruited
primarily from the community at periods years after
brain injury, and we were not successful in obtaining reli-
able documentation of acute severity of TBI. Document-
ing initial injury severity is critical to accurately establish
the relation between initial injury severity, later recovery
level, and response to cognitive treatment protocols.29, 30
Although the contribution of acute severity of injury
to long-term functional outcomes is still not definitive,
reliable documentation of associated medical conditions
and preinjury function would assist with improved char-
acterization of the sample.67, 68 Despite the shortcoming
of limited data on acute severity level, we are encour-
aged by the improvements in the SMART group, in
both cognitive function and self-rated daily function at
posttraining periods (both immediately post- and at 6-
months posttraining), as compared to the pretraining
level and as compared to a control group. Although
we do not anticipate that obtaining more definitive in-
formation regarding the initial injury documentation
would have significantly altered the findings; we pro-
pose that future studies should more rigorously specify
initial injury severity to validate the current findings.
Second, the current study included wide age ranges,
including age at injury (3–40 years), and age at training
(20–62 years) that may have affected the outcomes of the
study. For example, the majority of the participants (19
of 28, comparable number in both groups) sustained
their injury in their preteen, teen, or early adulthood
years (before the age of 25 years). Research has demon-
strated that frontal network myelination continues into
the early third decade of life (ie, into the early twenties),
and a TBI disrupts the maturation of frontal functions
that affect functional outcomes.85, 86 In support of this
evidence, Chapman and colleagues54 postulate that dis-
ruption to frontal networks (as in a TBI) prior to full mat-
uration may be associated with a neurodevelopmental
stall, that is, a failure to develop higher-order cognitive
skills, including gist-reasoning. Future studies could ex-
amine the effect of age at injury while examining higher-
level cognitive function, either as an outcome measure
or treatment factor. In addition to including a homoge-
nous group based on age at injury, future studies should
also consider age at training as a factor. It is possible that
one age group may have benefited more than the other.
However, this speculation needs further verification.
Third, the current study examined functional gains
on self-rated questionnaires that may represent one’s
perception of gains made posttraining. Assessment of
real-life task performance could provide a more accu-
rate characterization of benefits to daily function post-
training. In addition to addressing these 3 limitations,
future endeavors could examine the benefits of SMART
(a) beyond 6 months (eg, in yearly intervals), (b)inan
acute rehabilitation setting, and (c) in conjunction with
Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Gist-Reasoning Training 237
imaging measures examining brain changes and poten-
tial repair.
CONCLUSION
The current pilot study proposes a theory-based top-
down learning approach as an alternative to target-
ing specific impaired cognitive processes (ie, memory,
attention). Specifically, we propose that strategy-based
top-down modulation engaging strategic attention, in-
tegration, and innovation, has the potential to im-
prove executive control deficits that not only are of-
ten times significantly impaired years post-TBI, but
also are considered the most challenging to remediate.
Moreover, the current randomized small sample control
trial provides preliminary evidence that higher-level
gist-reasoning skills training delivered at chronic stages
postinjury (years or even decades postinjury) is benefi-
cial to untrained cognitive domains and indices of real-
life function both immediately and in the short-term, at
least up to 6 months posttraining.
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... The typical SMART training consists of 15 h of training conducted over 10 group sessions in the first 5 weeks and a final 3 h of training at spaced intervals over the next 3 weeks. Vas et al. (59) conducted an RCT comparing SMART to a psychoeducational control (Brain Health Workshop; BHW) in adults with TBI histories of >2 years and moderate functional impairment. The majority of participants' brain injuries were not specified as mild, moderate, or severe. ...
... The BHW training has been used in multiple studies as a comparison training program in cognitive training trials (52, 57,59,80). It consists of three, 3-h sessions of fact-based information about the brain but does not train cognitive strategies. ...
... This study builds upon prior research evaluating the effectiveness of SMART by involving a larger sample size of adults with PTSD and/or milder TBI histories and utilizing a shortened, 9-h version of the SMART protocol. Contrary to previous studies demonstrating superior cognitive gains in neurocognitive performance of longer versions of SMART compared to BHW in samples of patients with unclassified TBI with cognitive difficulties (57,59,104,105), we did not observe greater improvements in neurocognitive functioning or gist reasoning in participants enrolled in the shortened SMART protocol. Instead, both groups showed statistically and clinically significant improvements that were maintained over 6 months. ...
Article
Full-text available
Although there is evidence of mild cognitive impairments for many individuals with mild traumatic brain injury (mTBI) and posttraumatic stress disorder (PTSD), little research evaluating the effectiveness of cognitive training interventions has been conducted. This randomized controlled trial examined the effectiveness of a 9-h group cognitive training targeting higher-order functions, Strategic Memory Advanced Reasoning Training (SMART), compared to a 9-h psychoeducational control group in improving neurocognitive functioning in adults with mTBI and PTSD. A sample of 124 adults with histories of mild TBI ( n = 117) and/or current diagnoses of PTSD ( n = 84) were randomized into SMART ( n = 66) or Brain Health Workshop (BHW; n = 58) and assessed at three time points: baseline, following training, and 6 months later. Participants completed a battery of neurocognitive tests, including a test of gist reasoning (a function directly targeted by SMART) as well as tests of verbal, visual, and working memory and executive functioning, functions commonly found to be mildly impaired in mTBI and PTSD. The two groups were compared on trajectories of change over time using linear mixed-effects models with restricted maximum likelihood (LMM). Contrary to our hypothesis that SMART would result in superior improvements compared to BHW, both groups displayed statistically and clinically significant improvements on measures of memory, executive functioning, and gist reasoning. Over 60% of the sample showed clinically significant improvements, indicating that gains can be found through psychoeducation alone. A longer SMART protocol may be warranted for clinical samples in order to observe gains over the comparison group.
... generating multiple new ideas, solutions, and perspectives). SMART has been shown to promote improvements in both trained and untrained areas of cognitive functioning, including strategic attention (Gamino et al., 2009a(Gamino et al., , 2009b, innovation (Chapman et al., 2017;Young et al., 2021), meaning abstraction (Anand et al., 2010), gist-reasoning/integrated reasoning (Gamino et al., 2010;Vas et al., 2011;Young et al., 2021), fact-learning (Gamino et al., 2010), working memory (Cook et al., 2014(Cook et al., , 2020Gamino et al., 2009b;Vas et al., 2011), initiation (Gamino et al., 2009b), cognitive switching (Anand et al., 2010;Cook et al., 2020), and real-life executive function behaviors (Cook et al., 2020;Gamino et al., 2009b). Beyond yielding improvements in areas of cognitive function, as it was designed to address, SMART has also demonstrated unexpected benefits in mental health symptomatology (Vas et al., 2016;Young et al., 2021). ...
... generating multiple new ideas, solutions, and perspectives). SMART has been shown to promote improvements in both trained and untrained areas of cognitive functioning, including strategic attention (Gamino et al., 2009a(Gamino et al., , 2009b, innovation (Chapman et al., 2017;Young et al., 2021), meaning abstraction (Anand et al., 2010), gist-reasoning/integrated reasoning (Gamino et al., 2010;Vas et al., 2011;Young et al., 2021), fact-learning (Gamino et al., 2010), working memory (Cook et al., 2014(Cook et al., , 2020Gamino et al., 2009b;Vas et al., 2011), initiation (Gamino et al., 2009b), cognitive switching (Anand et al., 2010;Cook et al., 2020), and real-life executive function behaviors (Cook et al., 2020;Gamino et al., 2009b). Beyond yielding improvements in areas of cognitive function, as it was designed to address, SMART has also demonstrated unexpected benefits in mental health symptomatology (Vas et al., 2016;Young et al., 2021). ...
Article
Full-text available
Background The cognitive training Strategic Memory Advanced Reasoning Training (SMART) has been shown to improve symptoms of depression, anxiety, and stress when completed using in‐person delivery, but mental health outcomes have not yet been studied for online delivery of SMART. Methods Data was analyzed from 145 generally healthy adults participating in the BrainHealth Project pilot study who had access to 12 weeks of online self‐paced SMART and self‐reported mental health symptoms on the Depression Anxiety Stress Scale (DASS‐21) pre‐ and post‐training. We utilized linear models to examine the change in self‐reported symptoms of depression, anxiety, and stress following the 12‐week training period and to explore the influence of age, gender, and education on changes in symptomatology. Data from 44 participants who completed a follow‐up DASS‐21 6 months after completing SMART was used to explore the lasting impact of the training. Results Improvements in depression, anxiety, and stress symptoms were observed following online SMART, evidenced by a significant decrease in self‐reported symptoms on the DASS‐21. Improvement in self‐reported mental health symptomatology was maintained or continued to improve 6‐month post‐training. No significant effect of gender was observed, but findings motivate additional exploration of the effects of education and age. Conclusion Online SMART should be considered a low‐cost, high‐impact approach for supporting public mental health for generally healthy adults.
... Over the last decade, research implementing a high-performance brain training has shown improvements in higher-order cognitive performance, psychological well-being, and neural health. [1][2][3][4][5][6][7][8][9][10][11] This training, Strategic Memory Advanced Reasoning Training (SMART), is based on 25-plus years of scientific study [12][13][14][15][16][17][18][19][20][21] funded by the NIH, DoD, and other sources. ...
... The efficacy of SMART for improving higher-order cognitive functions has been demonstrated in nine randomized controlled trials, 3,10,[15][16][17][18][20][21][22] the two most comprehensive of which were the Healthy Adults study and the Traumatic Brain Injury (TBI) study. The Healthy Adults study was conducted following review and approval by the Institutional Review Boards at The University of Texas at Dallas, the University of Texas Southwestern Medical Center, and Cooper Institute (registered at ClinicalTrials.gov, ...
Article
Introduction Research shows that cognitive performance and emotional well-being can be significantly strengthened. A high-performance brain training protocol, Strategic Memory Advanced Reasoning Training (SMART), was developed by cognitive neuroscientists at The University of Texas at Dallas Center for BrainHealth based on 25-plus years of scientific study. Randomized controlled trials with various populations have shown that training and use of nine “SMART” strategies for processing information can improve cognitive performance and psychological health. However, the multi-week intensive training used in the laboratory is not practical for widespread use outside the laboratory. This article examines the efficacy of SMART when translated outside the laboratory to two populations (military/veterans and law enforcement) that received SMART in condensed time frames. Materials and Methods In two translation studies with healthy military personnel and veterans, 425 participants received between 6 and 10 hours of SMART over 2 days. In a third translation study, 74 healthy police officers received 9 hours of SMART over 3 days. Training was conducted by clinicians who taught the nine “SMART” strategies related to three core areas—strategic attention, integrated reasoning, and innovation—to groups of up to 25 participants. In all three translation studies, cognitive performance and psychological health data were collected before and immediately following the training. In one of the military/veteran studies, psychological health data were also collected 1 and 4 months following the training. Results In both translations to military personnel and veterans, there were improvements in the complex cognitive domains of integrated reasoning (P < .0001) and innovation (P < .0001) immediately after undergoing SMART. In the translation to police officers, there were improvements in the cognitive domains of innovation (P = .02) and strategic attention (P = .005). Participants in all three translations saw statistically significant improvements in self-reported symptoms of psychological health. The improvements continued among a subset of participants who responded to the later requests for information. Conclusions The results of translating to these two populations provide evidence supporting the efficacy of SMART delivered in an abbreviated time frame. The improvements in two major domains of cognitive function demonstrate that strategies can be taught and immediately applied by those receiving the training. The immediate psychological health improvements may be transient; however, the continued improvements in psychological health observed in a subset of the participants suggest that benefits may be sustainable even at later intervals.
... It prioritizes deeper level synthesis of information to obtain the "gist" while encouraging fluid and flexible thinking (Chapman et al., 2015. Delivered in a group format, the traditional 15-hour training has demonstrated improvement in cognitive functioning relative to control groups in samples of participants with TBI (Cook et al., 2014;Cook et al., 2015;Han et al., 2018;Vas et al., 2011;Vas et al., 2016) as well as cognitively healthy individuals (Anand et al., 2010;Chapman et al., 2016;Gamino et al., 2010;Gamino et al., 2014;Motes et al., 2014;Nguyen, 2017); it has never been evaluated in patients with PTSD specifically. The overall goal of the study was to target two conditions associated with mild cognitive deficits (mTBI and/or PTSD) and assess the effectiveness of a shorter, 9-hour version of the SMART training. ...
... Newspaper articles, stories, pictures, and audio or video clips were used to illustrate each strategy, and the application of strategies in daily life was emphasized and homework was assigned to practice skills between sessions. The Brain Health Workshop (BHW) has been used in multiple studies as a comparison training program in cognitive training trials (Binder et al., 2008;Novakovic-Agopian et al., 2011;Vas et al., 2011;Vas et al., 2016). It consists of sessions of fact-based information about the brain but does not train cognitive strategies. ...
Article
Background Patients with PTSD often voice concern over their perceived change in cognitive functioning. However, these negative appraisals do not always align with objective neuropsychological performance, yet are strongly predictive of PTSD symptom severity and self-reported functional impairment Methods The present study involves a secondary analysis examining the role of appraisals of a subsample of 81 adults with full or subthreshold PTSD on treatment outcomes in a randomized controlled trial investigating the effectiveness of a cognitive rehabilitation treatment, Strategic Memory and Reasoning Training (n =), compared to a psychoeducation control arm, the Brain Health Workshop (n =). Neither condition addressed PTSD symptoms, focusing instead on cognitive skills training and psychoeducation about the brain Results Intent-to-treat models showed statistically significant improvements for both groups on composite scores of executive functioning and memory. Additionally, both groups experienced clinically significant reductions in PTSD symptoms (assessed via the Clinician-Administered PTSD Interview) and the SMART group showed fewer negative appraisals about cognitive functioning following training. Change in appraisals of cognitive functioning was associated with change in PTSD as well as change in quality of life, with no differential associations based on group status. In contrast, neurocognitive test score changes were not associated with change in symptoms or functional outcomes. Limitations We did not collect data on other appraisals (e.g., self-efficacy), which could have further elucidated pathways of change. Conclusions Our findings suggest that interventions that do not directly target PTSD symptoms can lead to PTSD symptom change via change in appraisals of functioning.
... The following evidence-based recommendations for cognitive rehabilitation are based on the balance between (2019) x Peers et al. (2020) x Potvin et al. (2011) x Poulin et al. (2017) x Powell et al. (2012) x Prigatano & Wong (1999) x Prokopenko et al. (2019) x Radice-Neumann et al. (2009) x Richter et al. (2015) x Richter et al. (2018) x Rietdijk et al. (2020) x Rogan (2018) x Sander et al. (2002) x Schmitter-Edgecombe et al. (1995) x Scott et al. (2016) x Shum et al. (2011) x x Skidmore et al. (2015) x Skidmore et al. (2017) x Smania et al. (2013) x Spikman et al. (2010) x Storzbach et al. (2017) x Strangman et al. (2012) x Tam & Man (2004) x Thickpenny-Davis & Barker-Collo (2007) x Thompson et al. (2016) x x x Vanderploeg et al. (2008) x van de Ven et al. (2017) x Van Vleet et al. (2014) x Vas et al. (2016) x Vas et al. (2011) x Veisi-Pirkoohi et al. (2020) x Westerberg et al. (2007) x Winkens et al. (2009) x Withiel et al. (2019) x Wolf et al. (2016) x Wolf et al. (2021) x Yoo et al. (2015) x Zucchella et al. (2013) x Zucchella et al. (2014) x a Provide supplemental data to original study. b Abstract only; study not written in English. ...
Article
Background Cognitive-communication impairments following acquired brain injury (ABI) can have devastating effects on a person's ability to participate in community, social, vocational, and academic preinjury roles and responsibilities. Guidelines for evidence-based practices are needed to assist speech-language pathologists (SLPs) and other rehabilitation specialists in the delivery of cognitive rehabilitation for the adult population. Purpose The American Speech-Language-Hearing Association, in conjunction with a multidisciplinary panel of subject matter experts, developed this guideline to identify best practice recommendations for the delivery of cognitive rehabilitation to adults with cognitive dysfunction associated with ABI. Method A multidisciplinary panel identified 19 critical questions to be addressed in the guideline. Literature published between 1980 and 2020 was identified based on a set of a priori inclusion/exclusion criteria, and main findings were pooled and organized into summary of findings tables. Following the principles of the Grading of Recommendations Assessment, Development and Evaluation Evidence to Decision Framework, the panel drafted recommendations, when appropriate, based on the findings, overall quality of the evidence, balance of benefits and harms, patient preferences, resource implications, and the feasibility and acceptability of cognitive rehabilitation. Recommendations This guideline includes one overarching evidence-based recommendation that addresses the management of cognitive dysfunction following ABI and 11 subsequent recommendations focusing on cognitive rehabilitation treatment approaches, methods, and manner of delivery. In addition, this guideline includes an overarching consensus-based recommendation and seven additional consensus recommendations highlighting the role of the SLP in the screening, assessment, and treatment of adults with cognitive dysfunction associated with ABI. Future research considerations are also discussed.
... It is a skill that is extremely sensitive to TBI, 138 providing another avenue for assessment and also remediation. 139 Consequently, the clinician conducting a language assessment of a person with TBI should consider including complex and linguistically demanding tasks, including discourse. 140,141 Table 67.5 provides an overview of currently employed primary and high-level language tests 142-169 -standardized and nonstandardized-that research has proved to be sensitive in discriminating between TBI and control research participants and/ or have been recommended by the Academy of Neurologic Communication Disorders and Sciences (ANCDS) Practice Guidelines Group, 140 the ANCDS TBI Writing Committee led by Sohlberg and colleagues, 142 and the Moving Ahead Centre of Research Excellence in Brain Recovery. ...
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In two freestanding volumes, Textbook of Neural Repair and Rehabilitation provides comprehensive coverage of the science and practice of neurological rehabilitation. Revised throughout, bringing the book fully up to date, this volume, Medical Neurorehabilitation, can stand alone as a clinical handbook for neurorehabilitation. It covers the practical applications of the basic science principles presented in Volume 1, provides authoritative guidelines on the management of disabling symptoms, and describes comprehensive rehabilitation approaches for the major categories of disabling neurological disorders. New chapters have been added covering genetics in neurorehabilitation, the rehabilitation team and the economics of neurological rehabilitation, and brain stimulation, along with numerous others. Emphasizing the integration of basic and clinical knowledge, this book and its companion are edited and written by leading international authorities. Together they are an essential resource for neuroscientists and provide a foundation of the work of clinical neurorehabilitation professionals.
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Background: Adults with chronic traumatic brain injury (TBI) may experience long-term deficits in multiple cognitive domains. Higher-order functions, such as verbal memory, are impacted by deficits in the ability to acquire verbal information. Objective: This study investigated the effects of a neuroplasticity-based computerized cognitive remediation program for auditory information processing in adults with a chronic TBI. Methods: Forty-eight adults with TBI were randomly assigned to an intervention or control group. Both groups underwent a neuropsychological assessment at baseline and post-training. The Intervention group received 40 one-hour cognitive training sessions with the Brain Fitness Program. Results: The intervention group improved in performance on measures of the Woodcock-Johnson-III Understanding Directions subtest and Trail Making Test Part-A. They also reported improvement on the cognitive domain of the Cognitive Self-Report Questionnaire. Conclusions: The present study demonstrated that a neuroplasticity-based computerized cognitive remediation program may improve objective and subjective cognitive function in adults with TBI several years post-injury.
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Much effort has been made to understand the role of attention in perception; much less effort has been placed on the role attention plays in the control of action. Our goal in this chapter is to account for the role of attention in action, both when performance is automatic and when it is under deliberate conscious control. We propose a theoretical framework structured around the notion of a set of active schemas, organized according to the particular action sequences of which they are a part, awaiting the appropriate set of conditions so that they can become selected to control action. The analysis is therefore centered around actions, primarily external actions, but the same principles apply to internal actions—actions that involve only the cognitive processing mechanisms. One major emphasis in the study of attentional processes is the distinction between controlled and automatic processing of perceptual inputs (e.g., Shiffrin & Schneider, 1977). Our work here can be seen as complementary to the distinction between controlled and automatic processes: we examine action rather than perception; we emphasize the situations in which deliberate, conscious control of activity is desired rather than those that are automatic.
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The current study reviews the attention training literature after an acquired brain injury using mere-analytic procedures. Through computerized searches we identified 30 relevant studies involving a total of 359 patients. Overall performance, measured by d(+), improved significantly after training. Then the set of 30 studies were categorized according to whether the study evaluated training efficacy by comparing pre- and posttraining scores only or included a control as well. Results show that performance improved significantly after training when assessed by the pre-post only measure, but nut in the pre-post with control condition; Further analyses showed that performance in studies providing specific skills training improved significantly, whereas performance in studies providing general attention training did not. The implications of these results Tor rehabilitation are discussed. (C) 2000 Academic Press.
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Human problem-solving performance (i.e., the challenge to accomplish a specified result, often under prescribed conditions; cf. Oxford English Dictionary) is very often disturbed in brain-injured people. However, the term “impaired problem solving” is very broad and so indefinite that it does not really help to explain what is wrong with the complex cognitive process after brain damage.
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Attention can be focused volitionally by “top-down” signals derived from task demands and automatically by “bottom-up” signals from salient stimuli. The frontal and parietal cortices are involved, but their neural activity has not been directly compared. Therefore, we recorded from them simultaneously in monkeys. Prefrontal neurons reflected the target location first during top-down attention, whereas parietal neurons signaled it earlier during bottom-up attention. Synchrony between frontal and parietal areas was stronger in lower frequencies during top-down attention and in higher frequencies during bottom-up attention. This result indicates that top-down and bottom-up signals arise from the frontal and sensory cortex, respectively, and different modes of attention may emphasize synchrony at different frequencies.
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Post-traumatic amnesia (PTA) is a transient sequela of closed head injury (CHI). The term PTA has been in clinical use for over half a century, and generally refers to the subacute phase of recovery immediately after unconsciousness following CHI. The duration of PTA predicts functional outcome after CHI, but its pathophysiological mechanism is not known. This paper compares current methods of determining the duration of PTA, summarizes reports on neuropsychological deficits in PTA, reviews available data that allow inferences about its mechanism, and suggests methods for further exploration of its pathophysiology.
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Suggestions for improving text understanding often prescribe activating prior knowledge, a prescription that may be problematic if students do not have the relevant prior knowledge to begin with. In this article, we describe research about a method for developing prior knowledge that prepares students to learn from a text or lecture. We propose prior knowledge that prepares students to learn from a text or lecture. We propose that analyzing contrasting cases can help learners generate the differentiated knowledge structures that enable them to understand a text deeply. Noticing the distinctions between contrasting cases creates a "time for telling"; learners are prepared to be told the significance of the distinctions they have discovered. In 3 classroom studies, college students analyzed contrasting cases that consisted of simplified experimental designs and data from classic psychology experiments. They then received a lecture or text on the psychological phenomena highlighted in the experiments. Approximately 1 week later, the students predicted outcomes for a hypothetical experiment that could be interpreted in light of the concepts they studied. Generating the distinctions between contrasting cases and then reading a text or hearing a lecture led to more accurate predictions than the control treatments of (a) reading about the distinctions between the cases and hearing a lecture, (b) summarizing a relevant text and hearing a lecture, and (c) analyzing the contrasting cases twice without receiving a lecture. We argue that analyzing the contrasting cases increased students' abilities to discern specific features that differentiated classes of psychological phenomena, much as a botanist can distinguish subspecies of a given flower. This differentiated knowledge prepared the students to understand deeply an explanation of the relevant psychological principles when it was presented to them. These results can inform constructivist models of instruction as they apply to classroom activities and learning from verbal materials. In particular, the results indicate that there is a place for lectures and readings in the classroom if students have sufficiently differentiated domain knowledge to use the expository materials in a generative manner.