Evaluation of use of reading comprehension strategies to improve reading comprehension of adult college students with acquired brain injury.

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Evaluation of use of reading comprehension strategies to improve reading comprehension of adult college students with acquired brain injury a

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Gina G. Griffiths , McKay Moore Sohlberg , Cecilia a

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Kirk , Stephen Fickas & Gina Biancarosa

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Communication Disorders and Sciences, University of Oregon, Eugene, OR, USA Published online: 25 Feb 2015.

To cite this article: Gina G. Griffiths, McKay Moore Sohlberg, Cecilia Kirk, Stephen Fickas & Gina Biancarosa (2015): Evaluation of use of reading comprehension strategies to improve reading comprehension of adult college students with acquired brain injury, Neuropsychological Rehabilitation: An International Journal, DOI: 10.1080/09602011.2015.1007878 To link to this article: http://dx.doi.org/10.1080/09602011.2015.1007878

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Neuropsychological Rehabilitation, 2015 http://dx.doi.org/10.1080/09602011.2015.1007878

Evaluation of use of reading comprehension strategies to improve reading comprehension of adult college students with acquired brain injury


Gina G. Griffiths, McKay Moore Sohlberg, Cecilia Kirk, Stephen Fickas, and Gina Biancarosa Communication Disorders and Sciences, University of Oregon, Eugene, OR, USA (Received 19 March 2014; accepted 9 January 2015)

Adults with mild to moderate acquired brain injury (ABI) often pursue postsecondary or professional education after their injuries in order to enter or re-enter the job market. An increasing number of these adults report problems with reading-to-learn. The problem is particularly concerning given the growing population of adult survivors of ABI. Despite the rising need, empirical evaluation of reading comprehension interventions for adults with ABI is scarce. This study used a within-subject design to evaluate whether adult college students with ABI with no more than moderate cognitive impairments benefited from using reading comprehension strategies to improve comprehension of expository text. Integrating empirical support from the cognitive rehabilitation and special education literature, the researchers designed a multi-component reading comprehension strategy package. Participants read chapters from an introductory-level college anthropology textbook in two different conditions: strategy and no-strategy. The results indicated that reading comprehension strategy use was associated with recall of more correct information units in immediate and delayed free recall tasks; more efficient recall in the delayed free recall task; and increased accuracy recognising statements from a sentence verification task designed to reflect the local and global coherence of the text. The findings support further research into using reading comprehension strategies as an intervention approach for the adult ABI population. Future research needs include identifying how to match particular reading comprehension strategies to individuals, examining whether reading Correspondence should be addressed to McKay Sohlberg, Communication Disorders & Sciences, University of Oregon, Eugene, OR97405. E-mail: [email protected] This research was supported by a grant from the National Science Foundation. # 2015 Taylor & Francis

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GRIFFITHS, SOHLBERG, KIRK, FICKAS, AND BIANCAROSA

comprehension performance improves further through the incorporation of systematic training, and evaluating texts from a range of disciplines and genres. Keywords: Acquired brain injury; Reading; College; Intervention; Adult


INTRODUCTION Adult survivors of acquired brain injury (ABI) often enroll in post-secondary education or professional training after their injuries in order to begin, continue, or modify career paths (Ackerman, DiRamio, & Mitchell, 2009; Kennedy, Krause, & Turkstra, 2008; Stewart-Scott & Douglas, 1998; Todis, Glang, Bullis, Ettel, & Hood, 2011). An increasing number of these adults are experiencing academic failure because problems with reading comprehension interfere with learning (Kennedy, Krause et al., 2008; MacLennan & MacLennan, 2008; Sohlberg, Fickas, & Griffiths, 2011). The number of younger adults pursuing education following traumatic and non-traumatic acquired brain injuries is growing, in part due to the rise in returning injured soldiers taking advantage of education benefits, student athletes managing persistent concussion effects, as well as higher incidences of stroke in young adults and increased rates of survival of individuals with brain cancer (Adler et al., 2011; Faul, Xu, Wald, & Coronado, 2010; George, Tong, Kuklina, & Labarthe, 2011; Gessel, Fields, Collins, Dicks, & Comstock, 2007; Gilchrist, Thomas, Xu, McGuire, & Coronado, 2011; Harrison, 2010; Hoge et al., 2008).

Reading comprehension following acquired brain injury Responding to the needs of student readers with ABI requires developing intervention methods that address the reading challenges imposed by cognitive impairments. The RAND Reading Study Group (2002), addressing researchers whose purpose is to inform, develop and evaluate intervention approaches, emphasised the importance of understanding reading comprehension as a dynamic process between the reader, the text, and the reading activity, all situated within a sociocultural context. Adults with mild to moderate ABI can frequently demonstrate adequate reading comprehension within routine daily tasks such as reading a menu or social media, or following a set of directions (Lezak, Howieson, & Loring, 2012). These adults can often demonstrate the ability to extract the main idea, supporting details, and produce basic inferences after reading a newspaper article, or an invoice for a bill (Lezak et al., 2012; Salmen, 2004). The adults who participated in the current study could read for these purposes but when faced with reading comprehension demands for the


READING COMPREHENSION INTERVENTION AFTER ABI

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purposes of learning new content – described as reading-to-learn in educational research, they reported struggling. Reading-to-learn includes extraction of information but also requires continual construction, integration and updating of content while reading is still in process (Biancarosa & Snow, 2004). Unfortunately, our understanding of how cognitive impairments in adults with ABI contribute to difficulties with reading comprehension is limited and what evidence is published comes from experimental reading tasks that bear little resemblance to the reading demands encountered outside of the laboratory(Laatsch & Krisky, 2006; Schmitter-Edgecombe & Bales, 2005). The limited research with the ABI population, together with research from other cognitively impaired populations is beginning to document that deficits in attention, working memory and executive processes have the potential to affect the reading comprehension process (Caretti, Cornolid, DeBeni, & Romano, 2005; Schmitter-Edgecombe & Bales, 2005; Stine-Morrow, Milinder, Pullara, & Herman, 2001). The cognitive psychology literature also points to the requisite role these cognitive processes play in reading comprehension (Schmitter-Edgecomb & Bales, 2005; Stine-Morrow, Soederberg,-Miller, Gagne, & Hertzog, 2008). For the purposes of reading-to-learn, attention, working memory and executive functions are interdependent; they are all required for the selection and organisation of incoming information; the retrieval and transfer of information to and from long-term memory; and the active manipulation, integration and construction of information (Baddeley, 2000; 2002; Lezak et al., 2012; Sohlberg & Turkstra, 2011). The limited research that has investigated reading comprehension and cognition in adults with acquired brain injury supports a relationship between specific cognitive impairments and reading comprehension performance (Laatsch & Krisky, 2006; Mann, 2006; Schmitter-Edgecombe & Bales, 2005; Salmen, 2004; Tompkins, Bloise, Timko, & Baumgaertner, 1994). Recent work comparing reading comprehension performance of adults with ABI to matched controls has suggested students with brain injury struggle to recognise paraphrased information as measured by a sentence verification task and recall fewer communication units as measured by a free recall task(Sohlberg et al., 2011). These findings aligned with a study by Schmitter-Edgecombe and Bales (2005) that compared think-aloud comments of readers with severe ABI to controls produced after reading each sentence of a narrative. Compared to controls, readers with ABI were more likely to be restricted to the content of the recently read sentence. Readers in that study did not demonstrate integration of ideas across the narrative compared to controls. Researchers hypothesised that differences in working memory contributed to the difference (Schmitter-Edgecombe & Bales, 2005).


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Evidence for suppression difficulties. There is some suggestion that readers with brain injury struggle with suppression during reading (Laatsch & Krisky, 2006). When comparing a group of 12 adults with TBI and 12 controls matched for age, gender, and education on a multivariate composite of cognitive variables, significant differences were found on the CPT-II commission measure implicating a possible relationship between suppression abilities and reading comprehension (Sohlberg, Griffiths, & Fickas, 2014). According to attentional control theory, when individuals have diminished suppression ability, they must exert more effort to employ top-down attentional control to relevant stimuli to compensate for this diminished ability (Derakshan & Eysenck, 2009). As such, problems with suppression manifest in reduced speed of processing. If suppression issues are problematic for readers with ABI, this should be reflected in speed of processing tasks as well as commission tasks (Derakshan & Eysenck, 2009). Slowed speed of processing during reading tasks in the ABI population has been documented in several recent studies (Sohlberg et al., 2014; Sullivan, Griffiths, & Sohlberg, 2014). A comparison of veterans with TBI with matched controls on an experimental reading comprehension task showed that time spent reading test paragraphs and test questions, as well as time responding to test questions were more than double for the TBI group compared to the control group; no differences in accuracy of responses to questions was found (Sullivan et al., 2014). In the Sohlberg et al. (2014) study, rate of reading, as measured via an oral reading fluency task, revealed significant differences between participants with TBI and matched controls. Together, these results suggest that relative to matched unimpaired readers, both silent and oral reading rate for text-level material is significantly slower for readers with brain injury (Sohlberg et al., 2014; Sullivan et al., 2014). Accordingly, as conceptualised by the structure building framework (SBF), a slowed reading rate may represent difficulties with suppression, meaning readers may need to exert more effort to build coherent structures during reading comprehension. Further evidence that difficulties with suppression may affect reading comprehension was found in a functional magnetic imaging study that compared neurological activity during reading comprehension of three adult subjects with a history of severe traumatic brain injury to the activity of matched controls (Laatsch & Krisky, 2006). The neurological activity of the subjects with TBI was greater overall than the controls, and more areas of the brain were activated. The authors interpreted this pattern as potential evidence of difficulties with suppression (Laatsch & Krisky, 2006). Research conducted with adults with ABI evaluating discourse-level processes other than reading offers insights into the role cognitive impairments may play in reading comprehension difficulties (Brookshire, Chapman, Song, & Levin, 2000; Chapman, 1997; Moran & Gillon, 2005; Moran,



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Kirk, & Powell, 2012; Mozeiko, Leˆ, Coelho, Krueger, & Grafman, 2011). Brookshire and colleagues (2000) found that deficits in executive function predicted performance of individuals with ABI on a narrative production test better than site and extent of lesion. Similarly Mozeiko et al. (2011) showed that executive function and memory measures predicted performance on a measure of storytelling. Fertsl, Walther, Guthke, and Von Cramon (2005) compared narrative listening comprehension abilities in adults with left and right hemispheric brain damage, TBI and uninjured controls. Results suggested that impairments in alertness, executive function and memory were associated with performance decrements. Collectively the research on discourse-level processes in people with brain injury supports the role that impairments in working memory and executive function play in discourse performance. In both expressive tasks and listening comprehension tasks, individuals with ABI struggled to structure discourse content. Without an apparent structural frame, they have difficulty retaining details and generating inferences in listening comprehension tasks, and generating sufficient and appropriate relevant content in expressive tasks. Current models of reading comprehension illuminate the requisite cognitive processes involved in reading comprehension and provide direction for both intervention and assessment (e.g., Kintsch, 1988; 2004; Verhoeven & Perfetti, 2008). A model of reading comprehension with particular relevance to the ABI population is the structure building framework (SBF) that suggests reading comprehension begins through the activation of memory nodes stimulated by incoming information (Gernsbacher, 1991, 1997). Comprehension then evolves through three component processes: (1) laying a foundation structure, (2) mapping incoming information onto the foundational structure, and (3) shifting to establish new structures when incoming information is less coherent with the previous information (Gernsbacher, 1991, 1997). The SBF is centred upon two general cognitive processes that dominate many connectionist theories of comprehension and cognition: enhancement and suppression (Kintsch, 1988; Gernsbacher, 1991, 1997). In the SBF, these two processes serve as mechanisms for spreading or inhibiting activation during the process of building coherent mental structures (Gernsbacher, 1997). Although specific cognitive processes are not addressed under the SBF, inefficient suppression could be related to a number of cognitive problems such as inattention, impaired working memory, and executive dysfunctions (Coelho et al., 2013). The reading comprehension intervention developed and evaluated in the current study aimed to compensate for the effects of cognitive impairments on reading to learn. The focus of this study was on adults with acquired brain injury who currently experience problems with reading comprehension that could not be explained by the presence of frank linguistic or visual deficits.

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Intervention for reading comprehension deficits


The research evaluating reading comprehension intervention options for adults with cognitive impairments after ABI is extremely limited. However, evidence from the fields of cognitive rehabilitation and reading education provide a strong basis for considering reading comprehension strategies as an intervention approach. Contributions from cognitive rehabilitation literature. Metacognitive strategy training is a well-validated intervention approach for improving high-level cognitive functions, including academic performance (Cicerone & Giacino, 1992; Kennedy & Coelho, 2005, Kennedy et al., 2008; Lawson & Rice, 1989; Sohlberg, Ehlhardt, & Kennedy, 2005; Sohlberg & Mateer, 2001). Metacognition requires monitoring and being aware of one’s own thinking, and responding to that awareness by deliberately initiating an action that affects the thinking process (Dunlosky & Metcalfe, 2009; Sohlberg & Turkstra, 2011). The goal of metacognitive strategy training is for individuals to improve their ability to self-monitor their own thoughts, and to help regulate their approach to how they learn or use information to reach a goal (Kennedy & Coelho, 2005, Kennedy et al., 2008; Sohlberg et al., 2005; Sohlberg & Turkstra, 2011). Metacognitive strategy training for adults with ABI has been successfully implemented as part of overall academic support programmes (Kennedy & Krause, 2011; MacLennan & MacLennan, 2008). Kennedy and Krause (2011) reported outcomes of training two college students with TBI to use self-regulated study and learning strategies over two academic semesters. Strategies included both task-general and task-specific strategies organised around three themes: studying and learning, time management, and relating to others. For example, to improve self-regulation of time completion for a variety of study tasks, students were introduced to a “plan, do, review” strategy. To target student-specific studying and learning needs, students learned a range of strategies including note-taking strategies while reading and selftesting using created notes. Although individual differences were noted, both students ultimately endorsed the usefulness of most strategies, reported increased usage of strategies outside of therapy, and either improved academic standing or increased academic load (Kennedy & Krause, 2011). Contributions from regular and special education. Similar to the cognitive rehabilitation field, educational research has also supported the use of strategies to improve reading comprehension. Several meta-analyses provide compelling evidence for the use of reading comprehension strategies to improving comprehension in readers with learning disabilities (Berkeley, Scruggs, & Mastropieri, 2010; Edmonds et al., 2009; Gajria, Jitendra,



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Sood, & Sacks, 2007; Rosenshine & Meister, 1994; Souvignier & Mokhlesgerami, 2006). Gajria et al. (2007) reviewed research findings of 29 studies published between 1978 and 2005 that focused on interventions for comprehending written expository text in school-aged children or adolescents identified as learning disabled. Twenty-four of the articles focused on cognitive strategy instruction. Strategies included teaching students: to identify different types of text structures; to identify the main idea of a passage; to summarise what was read; to generate and answer questions about the text; or to develop cognitive maps of content. The meta-analysis of results indicated a very large overall effect size for cognitive strategy instructiond ¼ 1.83 (SD ¼ 1.05, n ¼ 1.05, n ¼ 15).1 Within the different types of strategies reviewed, identifying the main idea or generating main idea sentences by paraphrasing or summarising were particularly effective strategies (d ¼ 2.56, SD ¼ 1.09, n ¼ 6). Evidence to guide strategy selection. While some interventions have focused on utilisation of a single strategy, for example teaching students to identify and state the main idea in their own words (Ellis & Graves, 1990), increasing evidence supports the use of multiple strategies (Englert et al., 2009; Gajria et al., 2007; Graesser, 2007). The most well-supported reading strategies tend to facilitate performance in the following three areas: (1) activating background knowledge and anticipating content; (2) actively selecting and organising content while reading; and (3) synthesising and integrating content.

Reading comprehension strategy (RS) intervention Based on the available research, the authors of the current study developed a reading comprehension strategy (RS) intervention that facilitates the use of reading strategies at three different phases in the reading process: prereading, during reading, and post-reading. The strategies within each of these three reading phases were specifically selected with an eye to supporting enhancement and suppression processes as described by the SBF model. Text was presented electronically via a web-based user interface. Strategy use was facilitated through prompts and instructions integrated into the different phases of the reading process. Electronic delivery of content allows for consistent delivery of supports and is also a medium commonly utilised in college settings (Shelburne, 2009). The first phase of the intervention was the pre-reading phase. Pre-reading strategies guide readers through a preview phase where they review the 1 0. 80 or greater were considered large, at or near 0. 50 moderate, and 0. 20 small (Cohen, 1988).


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section headings in the target academic textbook chapter. The theoretical basis for the pre-reading strategies comes from the first component process of the SBF, laying a foundation structure (Gernsbacher, 1991, 1997). After the pre-reading phase, participants start the active reading phase which guides them to select up to three key ideas per paragraph, and then summarise key points in their own words. The strategies at this phase correspond to the second component of the SBF, mapping incoming information onto the foundational structure. The interface instructed them to write at least one, but no more than two sentences about what they had just read. Highlights and notes were automatically copied into a tool called My Notebook. As participants reached the end of a section, they were prompted to begin the review phase strategies that directed them to reread highlights and notes then write a three to five sentence summary of each section. The review phase is designed to enhance comprehension and build coherent mental structures and maps to the third component of the SBF model pertaining to the establishment of new structures (Gernsbacher, 1997). After reading all sections of the chapter, readers were presented with the summaries they wrote for each section and instructed to read each summary and then test their ability to recall each by “hiding it”. They were then instructed to click on each hidden summary to reveal it again in order to evaluate how well they did. The RS intervention in the current study built on an earlier pilot evaluation of the intervention (Sohlberg et al., 2011). In that study, individuals with and without TBI read expository text in two conditions: with RS prompts and without. Results showed a significant main effect for the strategy prompt condition, accounting for 67% of the variance between conditions. Review of individual measures showed verbal productivity was greater for both groups in the strategy prompt condition on two of three immediate free recall measures. Although participants did not produce more information as measured by number of communication units, free recalls did have significantly higher type –token ratios, a measure of lexical productivity, and words per communication unit, a measure of complexity. No significant differences were found between conditions on a sentence verification task (SVT) that included three different levels of statements: verbatim, paraphrase, and inference; however, ceiling effects on the SVT may have masked possible differences (Sohlberg et al., 2011). A post-hoc analysis revealed that differences in how participants within the TBI group actually used strategies after prompted predicted performance on inference statements (Griffiths & Sohlberg, 2012). Participants who highlighted more information but did not write summaries had lower scores than participants who highlighted less information and also wrote summaries (Griffiths & Sohlberg, 2012). Results from the pilot study informed development of dependent variables for the current study and led to refining strategy supports.


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Measurement of reading comprehension Free recall tasks are used both experimentally and clinically to evaluate cognitive-communicative abilities (Coelho, Ylvisaker, & Turkstra, 2005; LaingGillam, Fargo, & Robertson, 2009; Hay, & Moran, 2005; Magliano, Weimer˜ oz, & McNamara, 2002). Elicited samples are analysed Hastings, Millis, MuN to identify meaningful patterns pertinent to a given research or clinical question. Specific to individuals with TBI, discourse tasks such as story retell, story generation, and describing procedures have been used to evaluate cognitive-communicative functions including listening comprehension and discourse production abilities (e.g., Leˆ, Coelho, Mozeiko, Krueger, & Grafman, 2012). These cognitive-communicative functions have established parallels to reading comprehension (e.g., Leˆ et al., 2012). The aforementioned pilot study (Sohlberg et al., 2011) utilised a free recall task; participants were asked to pretend they were telling someone everything they had learned from what they read; discourse samples were recorded, transcribed and analysed (Sohlberg et al., 2011). Free recall samples were analysed to obtain three different measures of verbal productivity:(1) communication units (C-units, Loban, 1976), (2) C-units per minute (Loban, 1976), and (3) type–token ratios (Caspari & Parkinson, 2000). These measurements allowed a comparison of quantity of recall in the two conditions at two different grain sizes. C-units were used to measure number of complete thoughts recalled; words per C-unit were used to measure complexity; type–token ratios were used to measure lexical productivity. Within expository text, the introduction of new concepts and vocabulary is a primary focus (Lee & Spratley, 2010). As such, measuring quantity of information comprehended is particularly important when evaluating readingto-learn. In the current study, discourse samples from free recall tasks were analysed using a more fine-grained way of capturing total content recalled: correct information units (CIUs; Nicholas & Brookshire, 1993). Nicholas and Brookshire (1993) defined CIUs as words that are intelligible in context, and are accurate and relevant in relation to the topic. Words do not have to be used in a grammatically correct manner. The CIU measure allows a qualitative aspect of measuring total information recalled that also controls for redundancy. Research using CIUs has also found measuring efficiency of recall (i.e., CIUs per minute) has distinguished between TBI and controls on narrative recall tasks (Matsuoka, Kotani, & Yamasato, 2012). The current study included efficiency of recall as another measure, and further extended the methods used in the pilot study by eliciting two free recall tasks: one immediately after reading the chapter, and one after a 24-hour delay. In addition to measures of verbal productivity, measures used to evaluate the cohesiveness of discourse samples are frequently used to detect differences between groups or conditions on discourse processing tasks. For


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example, Coelho and colleagues found that adults with TBI produce fewer story grammar elements when recalling or generating stories compared to controls (Coelho et al., 2005); story grammar elements are cohesive devices that contribute to overall coherence of narratives. Evidence from studies with adolescents and young adults has shown that the cohesiveness of “think-aloud” discourse samples, as measured by latent semantic analysis, can be used as a predictor of reading comprehension performance, and can reveal what types of reading strategies, such as paraphrasing, bridging, and elaborating, participants are using as they read (Millis et al., 2004). Latent semantic analysis (LSA) relies on statistical calculation to estimate the meaning of a given passage by comparing it to a large corpus of related text (see Landauer, McNamara, Dennis, & Kintsch, 2007). Within a discourse sample, cohesiveness can be evaluated at two levels: locally, using sentenceto-sentence LSA, and globally, using paragraph-to-paragraph LSA (Landauer et al., 2007). In the current study, LSA was used to evaluate and compare cohesiveness of free recalls. Although discourse elicitation tasks have the potential to reveal meaningful differences in performance, the method relies heavily on expressive skills and recall. The Sentence Verification Task (SVT) is a widely used recognition task experimental paradigm in reading research (Carlisle, 1989; Royer, Hastings, & Cook, 1979; Stine-Morrow et al., 2008). In an SVT, participants read a set of statements after reading a passage. Readers must indicate whether they recognise the statements as being true or false based on the content that they read. In the pilot study, SVT items were developed following established procedures; for each passage items included five original or verbatim sentences, five paraphrase sentences, five inference sentences, and 10 foils (Carlisle, 1989; Royer et al., 1979; Stine-Morrow et al., 2008). All targets were true; foils were false. The SVT used in the pilot study showed promise but was limited by ceiling effects. In addition, reliability was variable. For this study the SVT was modified in two primary ways. First, two types of inference items were developed; the SVT items developed for this study included paraphrase, local inference items and global inference items. Second, item difficulty was increased by creating true and false statements for each type.

Research questions The purpose of this study was to evaluate whether using a multi-component, theoretically grounded reading comprehension strategy (RS) intervention improves reading comprehension performance of individuals with a history of acquired brain injury with mild-to-moderate cognitive impairments. Research questions were:



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1. Do adult college students with ABI recall more correct information (CIUs) during free recall tasks given immediately after using strategies in the RS condition compared to the no-strategy (NS) condition?Do they recall what they read with greater efficiency in the RS condition compared to the NS condition as measured by CIUs per minute?Is the cohesiveness of their free recalls better in the RS condition compared to the NS condition as measured by LSA? 2. Do adult college students with ABI recall more CIUs during free recall tasks given 24 hours after reading in the RS condition compared to the NS condition?Do they recall CIUs with greater efficiency in the RS condition?Is the cohesiveness of their free recalls better? 3. Are adult college students with ABI more accurate at recognising true and false paraphrase, local inference and global inference statements based on chapter content in the RS condition compared to the NS control condition? It was hypothesised that the data would support a positive response to all of the research questions and there would be significant improvement in comprehension and retention in the RS condition.

METHODS Experimental design Twenty-four adults with a history of acquired brain injury (ABI) were recruited to participate in a within-subject group comparison. Participants read two different expository chapters drawn from an introductory college textbook on world prehistory and archaeology (Chazan, 2011) under two different conditions: (1) the experimental or reading strategy (RS) intervention condition, and (2) the control or no-strategy (NS) condition. Two types of measures were used to assess reading comprehension performance: free recall tasks (immediate and delayed), and a sentence verification task.

Research procedures Recruitment. Students currently or previously enrolled in Coastline Community College’s (CCC) Acquired Brain Injury programme were invited to participate in the study. Participants had to have medically documented histories of brain injury and be at least six months post-injury; they could not have prior diagnoses of dyslexia or learning disabilities, or history of difficulty learning to read before injury; nor have had psychiatric or substance abuse issues that required inpatient or full-time outpatient treatment within the 12 months prior the study. Participants were considered for the study if they were between the ages of 18 and 55 years; acquired the English language


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before the age of 7 and were fluent speakers; had a 12th grade or equivalent level of education; were enrolled or planning to enrol in an academic community college course; had adequate vision, hearing and experience to be able to use a personal computer in order to read text on a screen and hear speech presented via the computer; and able to manipulate a mouse and keyboard for selecting and inputting information. At the time of the study participants needed to be able to comprehend three to four paragraph length material, such as a newspaper article, although they may have difficulty recalling what was read. Exclusion criteria included no diagnosis of dyslexia or learning disability or difficulty learning to read as a child, no substance abuse or psychiatric issues requiring hospitalisation in the previous 12 months and no work or study background in the fields of anthropology or archaeology so as to minimise the effect of prior knowledge on the evaluation of text comprehension (Kendeou & van den Broek, 2007). Twenty-four participants were enrolled in the study, 11 males and 13 females, with a mean age of 36 years (SD ¼ 11) and an education level of 14.08 years (SD ¼ 1.7). Fifteen identified as white, two as Hispanic, one as Asian, and one as a Pacific Islander; five did not provide race information. Thirteen participants had a traumatic ABI and 11 had a non-traumatic ABI. The mean time post-onset was 6 years, 9 months (SD ¼ 6.43). Four participants were at a Rancho Los Amigo scale of VII; the remaining 20 were at a level VIII. Twenty-two were employed prior to their injury; six reported being employed at the time of the study. Eighteen participants were enrolled in the Coastline Community College ABI programme at the time of the study; five had already graduated from the programme. Twenty-three of the 24 participants were also enrolled in at least one other regular community college course. Course instructors endorsed participants as having mild to moderate ABI. See Tables 1 and 2 for a summary of demographic characteristics. Research sessions. Participants completed a total of six research sessions: Three sessions were completed as part of condition one, and three were completed as part of condition two. Each condition consisted of one 2-hour session, one 90-minute session and one 30-minute session. All sessions were completed in classrooms at the CCC ABI programme campus. See Figure 1 for overview of session procedures. Sessions one and four: Condition orientation. Participants were oriented to the interface for each condition during the first session for that condition. User interfaces for both conditions were similar, with text presented within a scrollable window on a 32-inch computer screen, using identical fonts and similar navigation features. In the RS condition, strategy instructions and supports were integrated into the reading interface. For both conditions, participants were trained to typical digital reading tools found in PDF readers and

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READING COMPREHENSION INTERVENTION AFTER ABI TABLE 1 Summary of participant characteristics Demographic characteristics (n ¼ 24) Age and gender


Age Range (M ¼ 36, SD ¼ 11)

19– 30 31– 42 43– 55

Race

Male (n ¼ 11)

Female (n ¼ 13)

6 2 2

5 3 4

Education completed Level

No. of participants

Categoryb

Asian Black Hispanic Pacific Islander

1 0 2 1

White Other/not reported

15 5

No. of participants

High school/GED

8

Some college

8

Categoryb

2 year degree

1

4 year degree Graduate degree

5 2

Mgmt, business, science and arts Sales and service Nat’l resource. construct., and maint. Production, transport. and material moving Military specific Not working

Current college enrolment Additional courses in progress

0 1 2 3 –4

ABI programme students Matriculateda (n ¼ 19)

Graduated (n ¼ 5)

9 8 1 0

1 0 1 2

Occupation Prior

Currente

13

2

6 1

2 2

1

0

1 2d

0 17

a Current ABI students all take three courses specific to ABI programme. bRace and occupation categories based on 2010 Census standards (Federal Register, 2010; Humes, Jones, & Ramirez, 2011). cTwo also enrolled as students at time of injury. dBoth enrolled as students at time of injury. e All participants also enrolled as students except for one participant working in sales and service.

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GRIFFITHS, SOHLBERG, KIRK, FICKAS, AND BIANCAROSA TABLE 2 Summary of type and time post-onset of acquired brain injuries Time post-injury (M ¼ 6.75, SD ¼ 6.43)


Injury type TBI (n ¼ 13) Combat MVA Sports Non-TBI (n ¼ 11) CVA Infection/toxicity Tumor

1–2 years

3 –5 years

6+ years

0 1 1

0 5 0

1 5 0

3 2 0

3 0 0

2 0 1

TBI ¼ traumatic brain injury, MVA ¼ motor vehicle accident, CVA ¼ cerebrovascular accident (i.e., stroke).

Figure 1. Schedule for sessions.


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web, such as scroll bars, clickable buttons, and click-and-drag text selection. In the experimental condition, participants were also trained to follow the instruction steps displayed as part of each reading comprehension strategy. Sessions two, three, five and six: Reading and study sessions. Participants completed the experimental and control conditions in the remaining four sessions. Each condition occurred over two consecutive sessions: two and three, and then five and six, and were scheduled within a week of the condition orientation. Participants read one chapter in each condition; selected chapters are described in more detail in the Materials section below (Chazan, 2011). The order of presentation of conditions and chapters were counterbalanced across participants, resulting in four different permutations, which were repeated eight times. Participants followed a similar schedule of tasks during each condition. After a brief review of the interface, participants were told they would have 60 minutes to read a chapter drawn from an introductory college textbook on archaeology. They were advised that afterwards they would be asked by the researcher, “Tell me everything that you learned from the chapter you just read.” Immediately following the reading task, participants completed the immediate free recall task. The next day, they completed the delayed free recall task. After the delayed free recall task, participants completed the sentence verification task.

Materials Selection of reading content

The selection process and subsequent modifications were guided by the aim of establishing equivalency between the chapters while still preserving ecological validity. To control for the effects of writing style and discipline-specific conventions, chapter selection was made from one textbook: World prehistory and archeology, written by Dr. Michael Chazan, a practising anthropologist who teaches at the University of Toronto. The book, currently published in its second edition by Pearson Publishing (2011), is also used in the University of Oregon’s introductory anthropology course. Considerations for text selection included that the two selections be equivalent in terms of level of difficulty and overall text structure, and that they contain approximately 3000 words to allow participants to finish reading and studying the chapters within 60 minutes. When potential text selections that met criteria were identified, a number of discourse analysis procedures were utilised to compare content within the chapters to ensure equivalency in length, complexity, and general organisation. Two chapters were used in

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this study, designated chapter A and B. See Table 3 for a summary of text characteristics for each chapter.


Independent variable

Reading comprehension strategy intervention was the independent variable and had two levels: reading strategy (RS) condition and no-strategy (NS) condition. The RS condition divided the reading process into three phases: pre-reading, reading, and review. In the pre-reading phase, readers were guided to preview the text through presentation of chapter headings and initial sentences of each section. In the reading phase, participants were asked to highlight information and take notes as they read each section, then summarise each section before continuing to the next. In the review section, readers were presented with their section summaries, asked to read each one aloud, “hide” them by clicking on them, then test themselves by trying to recall each one. Figure 2 shows a screenshot of the interface delivering the RS condition for the active reading phase. In the control condition, readers read text presented within a standard PDF reader window. They were instructed to read the chapter, using the scroll bar or tools to navigate the chapter. As indicated above, they were provided with access to a word processing programme in an adjacent tab to the programme and advised they were free to take notes as they read. TABLE 3 Chapter characteristics Chapter A

Chapter B Quantity

Total words No. of different words Sentences Chapter sections

2762 840 144 6

Syllables per word Lexical density1 Sentence length in words

1.85 (SD ¼ 1.17) 30.4% 18.92 (SD ¼ 8.05)

2769 851 138 6 Complexity

Incidence of pronouns Sentence-to-sentence cohesion2 Gunning-Fox index3

1.99 (SD ¼ 1.16) 30.7% 20.21 (SD ¼ 8.87)

Cohesiveness 139.76 154.28 .24 (SD ¼ .19) .25 (SD ¼.19) Readability grade level 12.7 13.2

1 Number of content words (nouns, adjectives, verbs, adverbs)/total number of words; 2Measured through latent semantic analysis and ranges from – 1 to 1 (McNamara, Louwerse, Cai, & Graesser, 2005); 3Text readability metric.



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Figure 2. Screenshot of reading strategy interface facilitating use of highlighting and notetaking during active reading phase.

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Dependent variables


Two types of assessment tasks were administered to measure reading comprehension performance: free recall tasks, and a sentence verification task, described below. Free recall tasks. Participants completed two free recall tasks: one immediately after reading the chapter, and one the following day. Eliciting and analysing verbal discourse produced during or after individuals read written text is increasingly used to assess reading comprehension (Gillam, Fargo, & Robertson, 2009; Landauer et al., 2007; Magliano et al., 2002; Millis, Magliano, & Todaro, 2006; Wolfe & Goldman, 2005). Immediately following the reading task, participants completed the first free recall task. Free recalls were elicited using three prompts, that were given consecutively: (1) “Tell me everything that you learned from the chapter that you read”, (2) “Thinking about the chapter you read, tell me what you think are three of the biggest ideas”, (3) “Tell me what you think is the main purpose of the chapter”. The following four dependent variables were selected as measures to extract from the discourse samples: 1. 2. 3. 4.

Quantity of recall: Total correct information units (CIUs). Efficiency of recall: Correct information units per minute (CIUs/min). Local cohesion: Sentence to sentence LSA (LSAss). Global cohesion: Paragraph to paragraph LSA (LSApp).

The primary researcher and two research assistants transcribed discourse samples. The primary researcher supervised the transcription process, and watched 100% of the video samples to ensure reliability of transcriptions. CIUs were calculated via manual coding procedures described by Nicholas and Brookshire (1993). Manual coding was conducted independently for 50% of the transcripts by the primary researcher and a Master’s level research assistant, with results then compared. Inter-rater reliability of accuracy was calculated using Cohen’s Kappa with a criterion level of .90 (Stevens, 2009). To resolve discrepancies in counts or accuracy of categorisation, a third research assistant was consulted to make a final judgement. The LSA measures were calculated via an automated text analyser, following procedures of Landauer et al. (2007; Coh-Metrix). Reliability of immediate and delayed free recall results were measured by calculating Pearson’s product moment correlation for each chapter’s total scores for dependent variables. Results were significant for all dependent variables (CIUs: r ¼ .582, p ¼ .001; CIUs/minute: r ¼ .671, p ¼ .012; LSAss: r ¼ .81, p ¼ .0001; LSApp: r ¼ .74, p ¼ .005) .



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Sentence verification task. After the delayed free recall task, participants were instructed they would be completing a true/false test. This sentence verification test was administered only in the delay condition so as not to prime the recall test which allowed looking at the quantity and accuracy or retention. Participants were presented with a series of sentences and had to decide whether each sentence was true or false based on information from the chapter they had just read. Three types of sentences were developed for the SVT: paraphrase items, local inferences, and global inferences. A pilot study to validate the SVT was conducted involving volunteers enrolled in a Masters speech pathology course. The sample included 25 women and 3 males. Age ranged from 20 to 40 years, with a mean of 23 years (SD ¼ 6 months). Items were analysed and trimmed to eliminate items either missed or answered correctly by 22 or more. Ultimately, distributions of scores were normal and item difficulties were evenly distributed across chapters. To determine whether there were significant correlations between chapter A test scores and chapter B test scores, Pearson’s correlation statistic was conducted. Correlations were significant for between chapter comparisons for total scores (r ¼ .816, p , .05). Results were compared to participant responses on the Spot-the-Word subtest from the Speed of Comprehension and Language Processing. The subtest is used as measure of vocabulary level; vocabulary is a known predictor of reading comprehension (RAND Reading Study Group, 2002). A regression analysis was significant showing the SCOLP predicted overall scores on the combined SVTs (r ¼ .8, p ¼ .05). Reliability was further evaluated using results from the current study. Cronbach’s alpha was used to measure the internal consistency of items within each sentence type. Paraphrase items were judged borderline between adequate and good (a ¼ .789). Local inference items and global inference items were judged to be good (a ¼ .854, a ¼ .862). Pearson’s product moment correlation was used to measure the consistency between total scores for chapters A and B to help rule out a chapter effect (Wilson, 2005). Results were significant (r ¼ .611, p ¼ .0001) .

RESULTS Immediate free recalls Results from the immediate free recall tasks were analysed by conducting within-subject analysis of variance (ANOVA) for each dependent measure: (1) total correct information units (total CIUs), (2) efficiency of recall (CIUs/minute), (3) local cohesion (LSA, sentence-to-sentence), and (4) global cohesion (LSA, paragraph-to-paragraph). Alpha was adjusted to reduce risk of Type I error given multiple tests (a ¼ .05/4). Strategy condition


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was used as the independent variable (RS, NS); strategy order (1st, 2nd) and chapter (A, B) were included as additional fixed variables to account for order and chapter effects. The effect size index, partial eta squared (h2), was used to measure effect size when reporting the results of analyses of variance (ANOVAs; Levine & Hullet, 2002). Conventional effect sizes for h2 are as follows: small h2 ¼ .02, medium h2 ¼ .13, and large h2 ¼ .26 (Cohen, 1988). Significant differences were noted within subjects for the RS and NS conditions when comparing total correct information units, F(1, 26) ¼ 32.31, p ¼ .001, h2 ¼ .193. No significant differences were found with the efficiency variable or the local and global cohesion variables. Results of the analysis are reported together with delayed free recall results in Table 4.

Delayed free recalls Within-subject ANOVAs were also used to analyse the results of the delayed recall free recall task, using dependent and fixed variables as reported in the immediate free recall, and with Bonferoni adjustment of alpha (a ¼ .05/4). Significant differences were noted within subjects for the RS and NS conditions when comparing total correct information units, F(1, 26) ¼ 29.43, p ¼ .001, h2 ¼ .215, and when comparing correct information units per minute, F(1, 26) ¼ 8.12, p ¼ .005, h2 ¼ .234. No significant differences were found with the local and global cohesion variables. Results of the analysis are reported with the immediate free recall results in Table 4. TABLE 4 Mean for dependent variables in immediate and delayed recall task with ANOVA results No strategy

CIUs CIUs/min LSASS LSAPP

I D I D I D I D

Strategy

Mean

SD

Mean

SD

F

p

h2

65.33 32.00 28.58 23.33 .26 .29 .31 .31

30.04 19.55 4.63 11.48 .09 .09 .04 .11

76.67 55.67 30.38 35.27 .25 .30 .35 .32

36.52 29.43 3.00 8.43 .17 .17 .11 .15

32.31 32.31 1.46 8.12 1.31 0.31 2.35 1.21

.001∗ .001∗ .235 .005∗ .212 .580 .165 .265

.193 .215 .175 .234 .158 .038 .031 .113

I ¼ Immediate, D ¼ Delayed; CIUs ¼ total correct information units; CIUs/minute ¼ efficiency of recall; LSAss 5 sentence-to-sentence latent semantic analysis for local cohesion; LSAPP ¼ paragraph-to-paragraph latent semantic analysis for global cohesion. Distribution of data for each variable was unimodal; LSA measure distributions were notable for a negative skew, consistent with ratio measures. No significant interaction effects with fixed variables were identified. ∗ p , .0125.


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Sentence verification tasks A comparison of sentence verification task scores in no-strategy and strategy conditions was conducted using MANOVA with the three different sentence types included as dependent variables (paraphrase, local inference, global inference), strategy condition as the independent variable; and strategy order and chapter fixed variables to account for possible order and chapter effects. Wilk’s test revealed significant differences between the two conditions, L ¼ .414, F(3, 15) ¼ 7.07, p ¼ .003, h2 ¼ .586. Examination of the ANOVAs for each of the three measures using Bonferoni adjustment of alpha (a ¼ .05/3 ¼ .016) revealed that participants scored better on the local and global inference statements in the RS condition compared to the NS condition. No difference was found between means on the paraphrase statements. No significant interaction effects with fixed variables were identified. Results of the ANOVA analyses are reported in Table 5.

DISCUSSION The purpose of this study was to evaluate whether using a multi-component, reading comprehension strategy (RS) package improves reading comprehension performance of individuals with a history of mild to moderate acquired brain injury. This study also identified research methods effective for evaluating reading comprehension of expository text in adults with ABI. Grounded in the structure building framework (SBF), the hypothesis of this study was that the RS package would support readers to build a coherent mental representation, or structure, of what they read. In turn, a coherent structure would facilitate better performance on the reading comprehension measures administered after participants read the academic text. Two types of measures were used: free recall tasks given at two points in time – immediately after reading each chapter and then again the following day, and sentence verification tasks given after the delayed recall task in each TABLE 5 Sentence verification task results No strategy

Paraphrase Local Global

Strategy

Mean

SD

Mean

SD

F

p

h2

5.81 4.71 5.67

1.94 1.34 1.74

6.52 6.57 7.10

1.75∗ 1.69 1.64∗

2.25 17.25 62.00

.152 .001∗ .029∗

.117 .504 .250

Ten points possible for each dependent variable. ∗ p , .05.


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condition. The findings from the two free recall tasks are discussed first, followed by a discussion of the findings from the sentence verification tasks. This section then reviews the limitations of this study, and considers implications for future research. Research Questions 1 and 2 asked whether readers with ABI would demonstrate better comprehension when using reading strategies compared to not using strategies as measured by the quantity, efficiency, and cohesiveness of immediate and delayed free recall of chapter content. Readers recalled more information when provided with the reading comprehension strategies. In both the immediate and delayed free recall tasks, participants produced more correct information units (CIUs) in the RS condition than the NS condition. In the RS condition of the immediate free recall task, participants produced on average 11.34 more CIUs; the effect of the strategies accounted for 19.3% of the variance in total number of CIUs produced. In the RS condition of the delayed free recall task, participants produced on average 23.68 more CIUs, with the effect of the strategies accounting for 21.5% of the variance. Although readers recalled on average 1.8 more CIUs per minute in the RS condition of the immediate free recall as compared to the NS condition, this difference was not significant. However, efficiency of recall was significantly different between conditions in the delayed free recall condition; readers recalled on average 11.94 CIUs per minute in the RS condition, with strategies accounting for 23.4% of the variance. That is, after a 24-hour delay, readers produced more information in less overall time if they had been provided with reading comprehension strategies during the reading session. No significant differences were noted in the free recall variables used as measures of local and global cohesion for either the immediate or delayed conditions. Overall, the results provide partial support for hypotheses 1 and 2. The increased CIUs in both the immediate and delayed recall strategy condition confirmed that quantity of information recalled is enhanced by the multi-component strategy intervention. Readers’ efficiency of recall, however, was only better in the strategy condition for the delayed free recall; no apparent improvement in efficiency was suggested when comparing the conditions in the immediate free recall. A few possibilities might account for these discrepancies in results: (1) perhaps the RS package facilitated improvement across some, but not all aspects of reading comprehension, (2) perhaps some measures were not sensitive to the differences in performance in the RS and NS conditions, and (3) perhaps research design issues, such as a low number of participants, or other sources of random error, limited detection of differences. An improvement in efficiency in the delayed free recall may reflect better integration of and access to content compared to the immediate free recall. Kintsch (1988), Magliano, Millis, Ozuru, and McNamara (2007), and



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others emphasise that the reading comprehension process continues after the physical reading activity ceases. In the SBF, integration occurs through a mechanism of enhancement that increases the activation of contextually relevant information (Gernsbacher, 1996). The increased activation of information within the framework may allow quicker retrieval of that content in the delayed free recall. Although readers recalled more CIUs in both recalls, and were more efficient in the delayed free recall, they did not demonstrate better cohesiveness of recall. The hypothesis was that a more coherent understanding of chapter content would be reflected through better cohesiveness of free recalls as measured by latent semantic analysis (Landauer, McNamara, Dennis, & Kintsch, 2013). At least three possibilities may account for this unexpected finding: (1) strategies may not target coherence of understanding as originally thought, (2) a change in coherence of understanding may not be reflected by a change in cohesiveness of free recalls, or (3) a change in cohesiveness of free recalls may not be captured by LSA as applied in this study.

Effects of strategy use on accuracy and type of recall Research Question 3 asked whether readers with ABI would perform better when provided reading strategies as measured by overall accuracy and response patterns on the sentence verification task. The results showed a significant relationship between the strategy condition and how participants performed on the sentence verification tasks. This relationship was demonstrated when the paraphrase, local and global statements were considered as a composite, and accounted for 58.6% of the variance in scores. When the three statement types in the sentence verification task were considered individually, strategy condition accounted for 50.4% of the variance in the local cohesion scores, and 25.0% of the variance in the global cohesion scores. Strategy condition did not have a differential influence on the scores of the paraphrase items. The lack of significant change on the paraphrase items was unexpected. As noted in the methods section, the internal reliability of these items was on the borderline between adequate and good, less than the other two categories of item types. One possible artefact of the test items is that the paraphrase items may have included more details compared to the local and global cohesion statements, which could have made them more challenging. The reading strategy intervention used in this study did not specifically target recall of facts and details. As an overall measure of better understanding, the findings from both the free recall tasks and the sentence verification are encouraging. The findings suggest that reading strategies improve not only quantity and efficiency of comprehension, as measured by the free recall task, but also the accuracy

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of understanding at the global and local level as measured by SVT. Certainly, in this early stage of research, inferences regarding what aspects of the actual comprehension process were measured must be made cautiously and tentatively. The measure is experimental, and further validation is needed to claim the purported constructs are adequately represented.


Study limitations In terms of methodological issues, a trade-off was evident between controlling for many known, potentially confounding variables. While the design did help constrain variability, the restrictions limit the ability to generalise the findings to other text structures and genres. In addition, participants were all either current or former participants in the Coastline Community College’s ABI programme; the limitation to one site may have introduced variability unique to that location and population. The lack of available validated reading comprehension measures necessitated using experimental measures, that is the sentence verification and free recall measures. In order to avoid priming the reader to content, the sentence verification test was given only in the delayed condition which meant there was no immediate measure for comparison. The constraints of the research design required implementing the reading comprehension strategies in a manner that does not necessarily match best clinical practices. The clinical reality is that not all clients need, or benefit from, the same reading comprehension strategies and supports; a more clinically effective approach will be to match strategies and supports to particular needs and abilities. Given the focus of the research questions and the constraints of the research design, systematic instruction was not provided. (Sohlberg & Mateer, 2001; Sohlberg & Turkstra, 2011). The inclusion of systematic instruction with RS training will be important to validate. The positive response to systematic instruction within the ABI population is well established. The materials and dependent measures were also experimental, and as such are more vulnerable to error than standardised measures would have been; findings need to be interpreted with caution. The current study included individuals with both traumatic and non-traumatic brain injuries. Although screening criteria disallowed participants with frank linguistic or vision field deficits associated with focal injuries, the population was nonetheless neurologically diverse. This article did not include further analysis of response to strategies by injury type, or by other variables that may influence responsiveness such as severity of injury, time post-onset, and demographic differences. Along with these factors, discerning between breakdowns in comprehension versus learning (i.e., encoding) may influence selection and response to strategies. The within-subject design controlled somewhat for these factors. Although these issues were beyond the


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scope of this article, understanding the influence of individual variables on response to strategies will be important in order to determine appropriateness of particular strategies for a given student.


Extending the findings to future research The findings of this study are considered preliminary and need to be subjected to further experimental rigour. They do, however, encourage further investigation into the use of reading comprehension strategies as an intervention approach for adults with ABI who complain of problems with reading after their injury. Given that jobs after college increasingly require knowledge in science, technology, engineering, and medicine (Lee & Spratley, 2010), evaluating reading comprehension performance and response to strategies in alternative disciplines will be particularly important. Evaluating the impact of reading comprehension strategies with participants from a range of settings is also crucial to discern between generalisable effects and setting specific effects. Besides additional validation studies regarding the impact of a general RS intervention, clinical intervention research is needed to incorporate and evaluate clinical best practices including systematic training and matching particular strategies to individuals. Intervention research will need to include developing or adapting tools drawn from related applied fields or the experimental literature. A major barrier facing reading research and intervention is the paucity of validated reading comprehension tools (Pearson & Hamm, 2005; RAND Reading Study Group, 2002; Sweet, 2005). The results from this study validate use of free recall and sentence verification tasks as methods for assessing the impact of reading comprehension interventions. Within free recall tasks, use of total correct information units and efficiency of recall were sensitive to differences between strategy and no-strategy conditions. Further evaluation of other discourse measures such as causal coordinator-to-participle ratios (Griffiths & Sohlberg, 2012) may provide additional insights into the differential impact of interventions.

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