Self-Regulation after Traumatic Brain Injury: A Framework for Intervention of Memory and Problem Solving

ABSTRACT

Self-regulation of behavior is mediated by the frontal lobes and commonly disrupted after a traumatic brain injury. The rehabilitation field is only now beginning to understand self-regulation as a set of dynamic relationships between metacognitive beliefs and knowledge, ongoing self-monitoring or self-assessment during activities, and self-control (i.e., strategy decisions). This article provides a framework for understanding self-regulated learning and problem solving, along with a summary of the existing intervention literature. We conclude by providing clinicians with principles that emphasize accurate self-monitoring and explicit instruction to connect self-monitoring to strategy decisions.

KEYWORDS

Metacognition - executive functions - self-monitoring - self-control - learning - generalization - strategy instruction

REFERENCES

• 1 Lezak M D. Neuropsychological Assessment. 3rd ed. New York; Oxford University Press 1995
• 2 Luria A R. Higher Cortical Functions in Man. New York; Basic 1980
• 3 Stuss D T, Levine B. Adult clinical neuropsychology: lessons from studies of the frontal lobes.  Annu Rev Psychol. 2002;  53 401-433
• 4 Courville C B. Pathology of the Central Nervous System. Mountain View, CA; Pacific 1937
• 5 Janowsky J S, Shimamura A P, Squire L R. Memory and metamemory: comparisons between patients with frontal lobe lesions and amnesic patients.  Psychobiology. 1989;  17 3-11
• 6 Shimamura A P, Squire L R. Memory and metamemory: a study of the feeling-of-knowing phenomenon in amnesic patients.  J Exp Psychol Learn Mem Cogn. 1986;  12 452-460
• 7 van Veen V, Cohen J D, Botvinick M M, Stenger V A, Carter C S. Anterior cingulate cortex, conflict monitoring, and levels of processing.  Neuroimage. 2001;  14 1302-1308
• 8 Bechara A, Damasio H, Tranel D, Anderson S W. Dissociation of working memory from decision making within the human prefrontal cortex.  J Neurosci. 1998;  18 428-437
• 9 Levine B, Stuss D T, Milberg W P, Alexander M P, Schwartz M, Macdonald R. The effects of focal and diffuse brain damage on strategy application: evidence from focal lesions, traumatic brain injury and normal aging.  J Int Neuropsychol Soc. 1998;  4 247-264
• 10 Cicerone K D, Dahlberg C, Kalmar K et al.. Evidence-based cognitive rehabilitation: recommendations for clinical practice.  Arch Phys Med Rehabil. 2000;  81 1596-1615
• 11 Stuss D T. Self, awareness, and the frontal lobes: a neuropsychological perspective. In: Strauss J, Goethals GR The Self: Interdisciplinary Approaches. New York; Springer-Verlag 1991: 255-278
• 12 Malkmus D, Booth B J, Kodimer C. Rehabilitation of the Head Injured Adult: Comprehensive Cognitive Management. Downey, CA; Professional Staff Association of the Rancho Los Amigos Hospital 1980
• 13 Ylvisaker M, Feeney T J. Collaborative Brain Injury Intervention: Positive Everyday Routines. San Diego; Singular Publishing 1998
• 14 Hacker D J, Dunlosky J, Graesser A C. Metacognition in Educational Theory and Practice. Mahwah, NJ; Lawrence Erlbaum Associates 1998
• 15 Pressley M, Ghatala E S. Self-regulated learning: monitoring learning from text.  Educ Psychol. 1990;  25 19-33
• 16 Reder L M. Implicit Memory and Metacognition. Mahwah, NJ; Lawrence Erlbaum 1996
• 17 Swanson H L. Instructional components that predict treatment outcomes for students with learning disabilities: support for the combined strategy and direct instruction model.  Learn Disabil Res Pract. 1999;  14 129-140
• 18 Flavell J H. Metacognition and cognitive monitoring: a new area of cognitive-developmental inquiry.  Am Psychol. 1979;  34 906-911
• 19 Nelson T O, Narens L. Metamemory: a theoretical framework and new findings.  Psychol Learn Motiv. 1990;  26 125-141
• 20 Fernandez-Duque D, Baird J A, Posner M I. Executive attention and metacognitive regulation.  Conscious Cogn. 2000;  9(2 pt 1) 288-307
• 21 Butterfield E C, Belmont J M. Assessing and improving the executive cognitive functions of mentally retarded people. In: Bialer I, Sternlicht M The Psychology of Mental Retardation: Issues and Approaches. New York; Psychological Dimensions 1977: 277-318
• 22 Hertzog C, Hultsch D. Metamemory in adulthood: differentiating knowledge, belief, and behavior. In: Hess TM Aging and Cognition: Knowledge Organization and Utilization. Advances in Psychology. Amsterdam, Netherlands; North-Holland 1990: 161-212
• 23 McGuire M J, Maki R H. When knowing more means less: the effect of fan on metamemory judgments.  J Exp Psychol Learn Mem Cogn. 2001;  27 1172-1179
• 24 Kennedy M R. Self-monitoring recall during two tasks after traumatic brain injury: a preliminary study.  Am J Speech Lang Pathol. 2004;  13 142-154
• 25 Dunlosky J, Kubat-Silman A K, Hertzog C. Training monitoring skills improves older adults' self-paced associative learning.  Psychol Aging. 2003;  18 340-345
• 26 Thiede K W, Anderson M CM, Therriault D. Accuracy of metacognitive monitoring affects learning of text.  J Educ Psychol. 2003;  95 66-73
• 27 Hertzog C, Dixon R A, Hultsch D F. Relationships between metamemory, memory predictions, and memory task performance in adults.  Psychol Aging. 1990;  5 215-227
• 28 Kennedy M R, Carney E, Peters S M. Predictions of recall and study strategy decisions after diffuse brain injury.  Brain Inj. 2003;  17 1043-1064
• 29 McGlynn S M, Schacter D L. Unawareness of deficits in neuropsychological syndromes.  J Clin Exp Neuropsychol. 1989;  11 143-205
• 30 Giacino J T, Cicerone K D. Varieties of deficit unawareness after brain injury.  J Head Trauma Rehabil. 1998;  13 1-15
• 31 Hartley L. Cognitive-Communicative Abilities Following Brain Injury. San Diego, CA; Singular Publishing 1995
• 32 Sohlberg M M, Mateer C A. Cognitive Rehabilitation: An Integrative Neuropsychological Approach. New York; Guilford Press 2001
• 33 Borkowski J G. Metacognitive theory: a framework for teaching literacy, writing, and math skills.  J Learn Disabil. 1992;  25 253-257
• 34 Kennedy M RT, Coelho C, Turkstra L, Ylvisaker M, Sohlberg M, Avery J. Technical Report on Intervention for Disorders of Executive Functions, Metacognition and Awareness after Traumatic Brain Injury.  Academy of Neurologic Communication Disorders and Sciences (ANCDS). http://www.ancds/PracticeGuidelines 2005; 
• 35 Newman A C, Garmoe W, Beatty P, Ziccardi M. Self-awareness of traumatically brain injured patients in the acute inpatient rehabilitation setting.  Brain Inj. 1999;  14 333-344
• 36 Allen C C, Ruff R M. Self-rating versus neuropsychological performance of moderate versus severe head-injured patients.  Brain Inj. 1990;  4 7-17
• 37 Hart T, Giovannetti T, Montgomery M W, Schwartz M F. Awareness of errors in naturalistic action after traumatic brain injury.  J Head Trauma Rehabil. 1998;  13 16-28
• 38 Prigatano G P, Altman I M. Impaired awareness of behavioral limitations after traumatic brain injury.  Arch Phys Med Rehabil. 1990;  71 1058-1064
• 39 Kennedy M R. Retrospective confidence judgements made by adults with traumatic brain injury: relative and absolute accuracy.  Brain Inj. 2001;  15 469-487
• 40 Schlund M W. Self awareness: effects of feedback and review on verbal self reports and remembering following brain injury.  Brain Inj. 1999;  13 375-380
• 41 Fischer S, Gauggel S, Trexler L E. Awareness of activity limitations, goal setting and rehabilitation outcome in patients with brain injuries.  Brain Inj. 2004;  18 547-562
• 42 Gioia G A, Isquith P K, Guy S C, Kenworthy L. Behavior Rating Inventory of Executive Function. Odessa, FL; Psychological Assessment Resources 2000
• 43 Turkstra L, Coelho C, Ylvisaker M et al.. Practice guidelines for standardized assessment for persons with traumatic brain injury.  J Med Speech-Lang Pathol. 2005;  13 ix-xxviii
• 44 Kennedy M RT. Self-regulated behavior in survivors of TBI: beliefs, online monitoring, and strategies. Presented at the Illinois Speech and Hearing Association meeting 2001 Arlington, IL;
• 45 Sherer M, Bergloff P, Boake C, High Jr W, Levin E. The Awareness Questionnaire: factor structure and internal consistency.  Brain Inj. 1998;  12 63-68
• 46 Beardmore S, Tate R, Liddle B. Does information and feedback improve children's knowledge and awareness of deficits after traumatic brain injury?.  Neuropsychol Rehabil. 1999;  9 45-62
• 47 Ownsworth T L, McFarland K, Young R. Self-awareness and psychosocial functioning following acquired brain injury: an evaluation of a group support programme.  Neuropsychol Rehabil. 2000;  10 465-484
• 48 Kennedy M RT, Yorkston K M. The effects of frontal injury on self-monitoring during verbal learning by adults with diffuse brain injury.  Neuropsychol Rehabil. 2004;  14 449-465
• 49 Kennedy M R, Nawrocki M D. Delayed predictive accuracy of narrative recall after traumatic brain injury: salience and explicitness.  J Speech Lang Hear Res. 2003;  46 98-112
• 50 Schmitter-Edgecombe M, Woo E. Memory self-awareness and memory self-monitoring following severe closed-head injury.  Brain Inj. 2004;  18 997-1016
• 51 Kennedy M R, Yorkston K M. Accuracy of metamemory after traumatic brain injury: predictions during verbal learning.  J Speech Lang Hear Res. 2000;  43 1072-1086
• 52 Keleman W L, Frost P J, Weaver III C A. Individual differences in metacognition: evidence against a general metacognitive ability.  Mem Cognit. 2000;  28 92-107
• 53 Cicerone K D. Remediation of “working attention” in mild traumatic brain injury.  Brain Inj. 2002;  16 185-195
• 54 Rebann M, Hannon R. Treatment of unawareness of memory deficits in adults with brain injury: three case studies.  Rehabil Psychol. 1995;  40 279-287
• 55 Randt C T, Brown E R, Osborne Jr D P. A memory test for longitudinal measurement of mild to moderate deficits.  Clin Neuropsychol. 1980;  2 184-194
• 56 Webster J S, Scott R R. The effects of self-instructional training on attentional deficits following head injury.  Clin Neuropsychol. 1983;  2 69-75
• 57 Freeman M R, Mittenberg W, Dicowden M, Bat-Ami M. Executive and compensatory memory retraining in traumatic brain injury.  Brain Inj. 1992;  6 65-70
• 58 Lawson M, Rice D. Effects of training use of executive strategies on a verbal memory problem resulting from closed head injury.  J Clin Exp Neuropsychol. 1989;  11 842-854
• 59 Ehlhardt L A, Sohlberg M M, Glang A, Albin R. TEACH-M: a pilot study evaluating an instructional sequence for persons with impaired memory and executive functioning.  Brain Inj. 2005;  19 569-583
• 60 Marlowe W B. An intervention for children with disorders of executive functions.  Dev Neuropsychol. 2000;  18 445-454
• 61 Cicerone K, Giacino J. Remediation of executive function deficits after traumatic brain injury.  Neurorehabilitation. 1992;  2 12-22
• 62 Burke W H, Zencius A H, Wesolowski M D, Doubleday F. Improving executive function disorders in brain-injured clients.  Brain Inj. 1991;  5 241-252
• 63 von Cramen D Y, Matthes-von Cramon G, Mai N. Problem solving deficits in brain injured patients. A therapeutic approach.  Neuropsychol Rehabil. 1991;  1 45-64
• 64 Fassotti L, Kovacs F, Eling P ATM, Brouwer W H. Time pressure management as a compensatory strategy training after closed head injury.  Neuropsychol Rehabil. 2000;  10 47-65
• 65 Rath J F, Simon D, Langenbahn D M, Sherr R L, Diller L. Group treatment of problem-solving deficits in outpatients with traumatic brain injury: a randomised outcome study.  Neuropsychol Rehabil. 2003;  13 461-488
• 66 Dunlosky J, Hertzog C, Kennedy M RT, Thiede K. The self-monitoring approach for effective learning.  Int J Cognitive Technol. 2005;  9 4-11
• 67 Sohlberg M M, Raskin S A. Principles of generalization applied to attention and memory interventions.  J Head Trauma Rehabil. 1996;  11 65-78