Effective Instruction: Optimizing Outcomes Following ABI

Part 1: Overview of Instruction for ABI

An educator, school psychologist, occupational therapist, and speech-language pathologist working with the following individuals with acquired brain injury (ABI) discover that:

• Ben, 10 years old — struggles with reading comprehension; he’s failing language arts.
• Elena, 28 years old — fails to complete all of her clerical tasks at work and is at risk for losing her job.

These two learners have one thing in common: they have not had systematic instruction to help them learn, generalize, and retain the information, skills and strategies they need to be successful in their daily activities. Instruction is one of the most important yet often over-looked aspects of working with children and adults with cognitive impairments due to ABI. Providing learners with clear instruction can help them learn skills and strategies that will help them be more successful at school, home, work, and in the community. In this issue of the Brain Injury Professional, we provide an overview of evidence-based instructional principles, and then apply these principles to instructional targets common to students and adults with cognitive impairments due to ABI.

Review of the Evidence

The field of neuropsychological rehabilitation has witnessed a rapid expansion of research dedicated to the topic of instruction over the past several years. Researchers have evaluated several instructional techniques and practices, including (a) errorless learning — minimizing or eliminating errors during the acquisition phase of learning (e.g., Baddeley & Wilson, 1994); (b) spaced retrieval — a form of distributed practice in which the learner is provided opportunities to successfully recall information over expanded time intervals (e.g., Melton & Bourgeois, 2005); and (c) systematic support — instructors grade the level of support they provide according to the severity of learner’s cognitive impairments and the stage of learning (e.g., Riley & Heaton, 2000). Various terms used to describe such support include “prompts,” “cues,” and “scaffolding” (e.g., Sohlberg & Turkstra in press; Ylvisaker et al., 2000). In a recent review of the literature on effective instruction for individuals with acquired memory impairments Ehlhardt et al. (2008) identified key instructional practices for use with this population.

• Clearly define the instructional target(s) (e.g., information, multi-step skills, cognitive strategies).
• Insure the target is relevant and personally meaningful to the client.
• Minimize errors during the acquisition phrase (i.e., errorless learning), particularly for those with more severe impairments.
• Provide high rates of correct practice.
• Provide opportunities to practice over increasing longer periods of time (i.e., spaced retrieval).
• Use multiple training examples.

These techniques must be flexible and individualized, taking into account the learner’s abilities, motivation, and task characteristics (Clare & Jones, 2008; Ehlhardt et al., 2008; Fillingham, Sage, & Lambon Ralph, 2006; Riley & Heaton, 2000; Sohlberg & Turkstra, in press). Although there is no single way to instruct someone with acquired cognitive impairments, research clearly shows that instruction must be carefully planned to include the specific features listed above. Over 40 years of researchin special education validates these same instructional techniques with both children and adults with learning challenges (Stein, Carnine, & Dixon, 1998; Swanson, 1999, 2001). This body of work, examining the most effective way to teach learners with different disability labels but similar functional challenges, is relevant to designing effective approaches for teaching individuals with ABI (Ylvisaker et al., 2005).

Central to effective instruction is the assessment-instructional cycle. This framework is comprised of four steps — assessment, instructional design, instructional delivery, and on-going assessment (see Figure 1 below) (Madigan, Hall, & Glang, 1997).

Effective Assessment-Instruction Cycle

Step 1. Assessment: Assessment is an essential first step in the instructional process.

Ask: What does the learner know and what are his/her current abilities?

• Conduct comprehensive background assessment: Assess the learner’s abilities and needs across multiple domains (e.g., cognitive-communicative, academic, social; vision, hearing, motor, etc.), using a variety of sources (i.e., standardized and informal assessment tools, observations across settings)
• Identify instructional goals: Determine the learner’s goals through interviewing the learner and relevant others (e.g., teachers, parents, spouses, co-workers)

Step 2. Instruction Design: Instructional design is an extension of the assessment process and should take place before instruction occurs.

Ask: What additional information/skills/strategies does the learner need to know?

1. Identify instructional target(s): Determine what the learner needs to know or be able to do in order to achieve his or her goal. Determine the type of instructional target from one of three broad categories:

• Information-Concepts: Information — specific facts or important pieces of information such as name or phone number; Concepts — an object, event, action, or situation that is part of a class of information (e.g., spelling regular vs. irregular words; sorting colored vs. white clothing).
• Multi-step skills/procedures: Multi-step tasks for specific activities such as making a sandwich, checking an appointment on a calendar, or turning in homework are broken down into small steps (i.e., task analysis).
• Rules-Cognitive Strategies: Rules — specific “if-then” connections between facts or concepts (e.g., If you see water on the floor, then mop it up.); Strategies — used to self-regulate behavior or thinking for either: (a) specific tasks such as PQRST (Preview, Question, Review, State, Test) for reading comprehension; or (b) a range of tasks such as Goal-Plan-Do-Review to facilitate goal planning and follow through.

2. Assess stage of learning: Once the instructional target has been determined, assess (i.e., take baseline data) to determine current level of performance on specific instructional target:

• Stage 1:Acquisition — the beginning stage; the learner has minimal or no knowledge of the instructional target;
• Stage 2: Generalization — acquisition achieved but the learner has yet to generalize to other contexts;
• Stage 3: Maintenance — the learner maintains generalized information, skills, and/or strategies over time.

Ask: What is the instructional environment(s)?

In order to facilitate generalization of learning across settings and people, it is important to include, early on in the instructional process, teaching in a variety of settings with different people.

• Identify places where teaching will occur: Determine where functional use of the target is expected to occur (e.g., classroom, office, reception desk, work site, grocery store, recreational events, etc).
• Identify people to include in the teaching process: Determine the people with whom the learner will use the instructional target (s) (e.g., classmates, teacher, spouse, co-workers, supervisors, community members, etc).

Ask: What do I need to prepare ahead of time?

• Design instructional lessons/materials/units: Organize and modify as needed the instructional materials (e.g., reading material, math problems, external aids). A key component of this step is breaking down complex skills into component parts (e.g., checking appointments using a PDA–step 1 turn on PDA; step 2 locate date; step 3 press the date . . .).
• Select teaching examples: Select and sequence multiple acquisition and generalization teaching examples. It is critical to consider the range of examples needed to teach most efficiently (e.g., to teach simple cooking, it is important to work with a variety of recipes and ingredients).
• Identify clear wording: Make sure directions/models are worded simply and clearly; develop an instructional script to keep wording consistent across examples.

Step 3. Instructional Delivery: Instructional delivery is what the instructor actually does during the class or therapy session.

Ask: What are the specific instructional delivery techniques that will be used?

• Modeling: Demonstrate target (s) and provide systematic support tailored to the learner’s abilities and stage of learning (1-3 above).
• Practice-Review: Provide learner with multiple practice opportunities distributed throughout each session (e.g., spaced retrieval) and provide review opportunities across sessions.
• Pacing: Appropriately pace modeling and practice trials at a rate consistent with the learner’s processing speed.
• Feedback: Provide immediate corrective feedback in response to errors; reinforce correct performance.
• Mastery: Train instructional targets to mastery before introducing new material. (See Table 1 for instructional techniques linked to learner’s characteristics).

Step 4: On-going Assessment: Conduct on-going assessment to determine the effectiveness of instruction.

Ask: How will I know if the instruction is effective?

• Collect data: Record the learner’s performance on instructional targets at the beginning of each training session.
• Reflect on/analyze patterns: Use the data to determine level of mastery and the need for modifying the design and delivery of instruction. Assess the learner's motivation and attitude to insure continued engagement in the instructional process.

Two hypothetical case examples are presented below to illustrate the assessment-instruction cycle. To better focus on the instructional component of each case, information on background assessment has been kept to a minimum.

CASE EXAMPLES

Student Case Example: Penny and Ben

Focus: Improving reading comprehension

Overview: Ben is a ten year-old in Penny’s 5th grade class who sustained an ABI one year ago while riding his bike. Ben is having difficulty with reading comprehension. Penny needs to assess Ben’s reading comprehension and design and deliver instruction in a group setting to help him improve this core academic area.

Step 1. Assessment: Assessment is an essential first step in the instructional process.

Ask: What does the learner know now?

• Background: The school psychologist’s assessment revealed moderate difficulty with new learning, but relatively spared attention and executive functions. Vision, hearing, and motor skills are within-normal limits. Results from a reading assessment suggest that Ben is able to read words and recall facts but has difficulty locating main ideas in a paragraph.
• Goal: Ben will identify the main idea and supporting details in grade-level reading material with 90% accuracy.

Step 2. Instruction Design: Instructional design is an extension of the assessment process and should take place before instruction occurs.

Ask: What additional information/skills/strategies does the learner need to know?

• Instructional target(s): Peggy determines that Ben does not understand the concept of main idea vs. supporting details,
• Stage of learning: Ben is currently at the acquisition stage of learning for comprehending main vs. supporting ideas; he can state the main idea in three out of ten paragraphs during baseline testing with grade-level material. He is not ready for generalization or maintenance.

Ask: What is the instructional environment(s)?

• Places: Penny will instruct Ben in a small group with five other students who are experiencing similar challenges. Once Ben achieves mastery in Penny’s classroom, she will work with Ben’s parents to practice this concept with him at home.
• People: Ben will be able apply the target concept with a variety of people, including Penny, classroom aides, peers, and parents.

Ask: What do I need to prepare ahead of time?

• Materials: Penny selects paragraph-length materials from published reading curricula.
• Examples: Penny initially chooses familiar, paragraph-length examples slightly below Ben’s grade level. Paragraphs range in length from two to three sentences to ten sentences. For initial instruction, she uses multiple-choice examples/non-examples of main ideas of each paragraph. As Ben masters the concept of main idea, Penny advances to more complex, grade-level material to facilitate generalization. Penny uses at least four to five different examples per lesson.
• Wording: Penny uses an instructional script that comes with the published reading program to insure clear, concise delivery. Here is a sample script from one of their first lessons together.

Sample script:

Teacher: The main idea of a paragraph tells what the whole paragraph is about.

Teacher: What does the main idea tell you?

Student: What the whole paragraph is about.

Teacher: Excellent. Ben please read the first paragraph.

Ben: Every day Sara got up early before school and took care of her dog, Fred. She took Fred for a walk then fed him before leaving for school. She took him for another walk after she finished her homework at night. Before going to bed, she combed his fur and gave him a doggy biscuit to clean his teeth.

Teacher: Nice job. Let’s figure out the main idea for this paragraph. Remember, the main idea tells what the whole paragraph is about. (Reads aloud the four choices on the board)

Teacher: The main idea is #3: Sara takes care of her dog. It tells you what the whole paragraph is about. The other choices only tell about part of the paragraph.

Teacher: Let’s do another example. (After two more paragraphs with Penny modeling how to identify the main idea, she asks another student to read a fourth paragraph again with four multiple choice options)

Teacher: Let’s review: What does the main idea tell you? (Calls on Ben.)

Ben: The main idea tells you what the whole paragraph is about.

[Teacher and Students review all main idea options]

Teacher: Is answer #2 the main idea for this paragraph? (Calls on another student.)

Student: No

Teacher: Why?

Student: Because it doesn’t tell about the whole paragraph.

Teacher: Tell me, is #3 is the main idea? Why or what not? (Calls on Ben.)

Ben: It’s not the main idea because it doesn’t tell about the whole paragraph.

Teacher: How about #1? (Calls on another student.)

Student: It is the main idea because tells about the whole paragraph.

Step 3. Instructional Delivery: Instructional delivery is what the instructor actually does during the class or therapy session.

Ask: What are the specific instructional delivery techniques that will be used?

• Modeling: In the sample script above, Penny models how to identify the main idea across three paragraphs followed by guided practice with a fourth paragraph. [Note: It is through practice with multiple examples that Ben begins to generalize the concept; she moves from simple conceptual understanding to strategic application.]
• Practice–Review: The students practice locating the main idea in simple paragraphs, selecting from multiple-choice options. Penny monitors and provides corrective feedback and praise.
• Pacing: Penny determines the pace of instruction by observing how her students are doing and paces the lesson to the average learner in the group. If they are responding correctly and fairly quickly, she moves briskly through the lesson. If they have difficulty, she provides more models of how to use the strategy. One cautionary note regarding instructional pacing — sometimes instructors make the mistake of slowing down instruction to match the response speed of students with articulation disorders or response latency. This is acceptable to a point, but extremely slow presentation can lead to distraction or confusion (e.g., the learner may have trouble tracking or remembering question).
• Feedback: If she notices Ben or any other student giving incorrect responses, Penny immediately corrects by providing the correct answer, and then having students practice another example.
• Mastery: Penny continues this exercise until all the students are able to identify the main idea in a multiple choice format with 90% accuracy without assistance. She then asks students to read simple paragraphs and state the main idea for each. If students do not correctly identify the main idea, she follows the correction procedure above. Once students can state the main idea with 90% accuracy, she moves to more complex paragraphs.

Step 4. On-going Assessment: Conduct on-going assessment to determine the effectiveness of instruction.

Ask: How will I know if the instruction is effective?

• Data: At the beginning of each session, Penny takes data to determine how well the students can find the main idea on a novel passage. This helps guide what she needs to focus on during that day’s lesson. If they have trouble, she will provide more practice. If they are doing well, she will move to more difficult examples, or on to a new skill.
• Reflection: After each session, Penny reflects on her teaching to determine what she might do differently in the next session. Following the above lesson for example, she determines that her pacing was a little slower than the group needed which was likely why some students were not attentive. She also determined that she needed to give more practice opportunities to help students master the strategy. She felt good about her instructional wording and feedback.

Adult Case Example: Alan and Elena

Focus: Completing all job-related tasks.

Overview: Alan is a job coach in a vocational re-entry program for adults with acquired brain injury. In consultation with a speech-language pathologist (SLP), he is providing twice weekly support and training to Elena, a 28-year-old woman who sustained a traumatic brain injury in a car crash. Elena is working in a doctor’s office. Her duties include filing medical charts, organizing the mail, stuffing envelopes, and answering the phone. After one month on the job her immediate supervisor reports that Elena is highly motivated, works well with other staff and patients, and is fielding phone calls very well. Her current challenges involve remembering to do her other clerical tasks; she gets distracted when she answers the phone or engages in conversation with patients and never completes her filing or mail work. Alan, Elena, and the office staff agree that they need to figure out a system for helping her remember to accurately and efficiently complete her filing tasks.

Step 1. Assessment

Ask: What does the learner know now?

• Background: Elena lives with her husband; they have no children. Neuropsychological testing revealed that Elena has significant difficulties with attention and working memory but has relatively spared new learning/memory and selected components of executive functions (e.g., initiation, planning). She has a mild tremor in both hands but it does not interfere with daily tasks. Vision and hearing are within normal limits. Initial vocational testing and further assessment by the SLP reveal that Elena might benefit from an external aid that would help cue her to complete all of her work tasks. The SLP, Alan, and Elena decide that instructing her to respond to regular alarms in the “tasks” program on her cell phone would be the most appropriate instructional target, since she always has her cell phone with her and this same skill could transfer to other daily tasks. (Note: They decide to delay teaching her how to program these alarms until she has mastered responding to alarms programmed by someone else.)
• Goal: Elena will complete all clerical work tasks 80% of the time, using her cell phone alarm to prompt task completion.

Step 2. Instruction Design

Ask: What additional information/skills/strategies does the learner need to know?

• Instructional target(s): Alan and the speech-language pathologist working with Elena determine that responding to the cell phone alarms and completing the prompted task is a multi-step skill. The steps include the following:
  • Step 1. Pick up the cell phone (when the alarm goes off)
  • Step 2. Read task (e.g., file charts, organize mail)
  • Step 3. Press Snooze
  • Step 4. Start task
  • Step 5. Press OK once alarm goes off again (These steps insure she has actually started the task before the alarm is turned off.)
• Stage of learning: After just a few sessions with the SLP working together at the vocational re-entry program office, Elena has mastered each of the above steps, consistently completing the steps during a role play (Stage 1–acquisition). The SLP taught Elena just 1-2 steps at a time until all 5 steps were mastered. Now Elena needs to generalize this 5-step skill to the work setting with Alan’s help and at home with her husband’s help. Once the skill is mastered, Alan will conduct maintenance checks.

Ask: What is the instructional environment(s)?

• Places: Elena will receive instruction at home and at work.
• People: While at work, Elena will be incorporate the new skill into her work among office staff and patients. At home, she will use the skill to prompt completion of home-based activities (e.g., laundry, cleaning) she does on her own.

Ask: What do I need to prepare ahead of time?

• Materials: Elena needs her cell phone and the materials needed to complete the targeted work and home tasks (e.g., files, envelopes, cleaning products).
• Examples: Alan and Elena generate a list of all the work tasks she has to do besides answering the office phone (e.g., filing, organizing mail, stuffing envelopes) and with her supervisor, agrees on a schedule for programming her cell phone alarms to go off, insuring there are sufficient practice opportunities to help her with skill generalization (e.g., a minimum of 6 alarms per shift; 2 each across 3 different tasks). Alan programs these alarms before the shift begins. Similarly, Elena and her husband develop a list of home tasks that require prompting via cell phone alarms.
• Wording: Alan uses an instructional script to insure clear, concise delivery. Here is a sample script:

[first alarm goes off at 9:00 am]

Alan: [Waits to see if Elena picks up the phone]

Elena: [She picks up the phone.] (Step 1 above)

Elena: It says ‘file charts’. (Step 2)

Alan: Okay. [waits to see if she does anything. When she doesn’t, he asks] And then?

Elena: Oh, then I press ‘Snooze’ [presses “Snooze”] (Step 3)

Alan: Great!

Elena: [initiates filing charts] (Step 4)

[alarm goes off again]

Alan: And now?

Elena: I press OK (Step 5)

Alan: Good job!

Elena: [continues filing charts]

Step 3. Instructional Delivery: Remember

Ask: What are the specific instructional delivery techniquesthat will be used?

• Modeling: Given Elena’s relatively mild impairments and skill-comfort using the cell phone, Alan provides minimal direct support up front, offering indirect questioning cues instead (e.g., And then? And now?) Should she forget a step, he increases the specificity of his support (e.g., Read what it says. Do the task.)
• Practice – Review: Elena practices the 5-step process at least six times per shift with Alan.
• Pacing: Alan adjusts his instructional pacing to match Elena’s day-to-day fluctuation in attention, fatigue, etc.
• Feedback: Alan provides immediate feedback concerning Elena’s recall of the 5-steps as well as her performance on the target task itself.
• Mastery: Elena continues to work on the 5-step skill at work and at home until mastered.

Step 4. On-going Assessment

Ask: How will I know if instruction is effective?

• Data: At the beginning of each session and throughout the course of her shift, Alan and Elena’s work supervisor take brief notes on how well she is completing her work tasks. Alan also checks in with her husband to see how she is doing at home with cell phone alarms to prompt task completion.
• Reflection: Before each work shift, Elena predicts how she will do with her 5-step skill. Then she and Alan reflect on her performance at the end of each shift, consulting with the work supervisor, as appropriate.

Summary

This series of articles introduces effective instructional practices for training individuals with ABI on personally-relevant information, skills, and strategies. The overview of the 4-stage assessment-instruction process was illustrated with two case examples that represent the age range, diagnoses, and instructional targets professionals may encounter. The purpose of this approach is to illustrate that time spent prior to actually beginning training — on assessment and instructional design — followed by clear, targeted instruction, delivery, results in faster mastery of skills and strategies, improved generalization, and greater retention. The readers are strongly encouraged to further explore evidence-based instruction through the resources listed below:

• Kennedy, M.R.T. & Coelho, C. (2005). Self-regulation after traumatic brain injury: A framework for intervention of memory and problem solving. Seminars in Speech and Language, 26, 242-255.
• Sohlberg, M.M., Ehlhardt, L., & Kennedy, M. (2005). Instructional techniques in cognitive rehabilitation: A preliminary report. Seminars in Speech and Language, 26, 268-279.
• Sohlberg, M.M., Kennedy, M.R.T., Avery, J., Coelho, C., Turkstra, L., Ylvisaker, M., & Yorkston, K. (2007). Evidence-based practice for the use of external aids as a memory rehabilitation technique. Journal of Medical Speech Pathology, 15(1), xv-li.
• Sohlberg, M.M. & Turkstra, L. (in press). Cognitive Rehabilitation: Teaching New Skills, Strategies and Facts to People with Acquired Brain Injury. New York: Guilford Press.

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