http://informahealthcare.com/bij ISSN: 0269-9052 (print), 1362-301X (electronic) Brain Inj, 2014; 28(13–14): 1748–1757 ! 2014 Informa UK Ltd. DOI: 10.3109/02699052.2014.955883

ORIGINAL ARTICLE

Psychometric properties of the college survey for students with brain injury: Individuals with and without traumatic brain injury Mary R. T. Kennedy1,2, Miriam O. Krause1, & Katy H. O’Brien1 1

Speech-Language-Hearing Sciences, University of Minnesota, Minneapolis, MN, USA and 2Communicative Sciences & Disorders, Chapman University, Orange, CA, USA Abstract

Keywords

Purpose: The psychometric properties of the college challenges sub-set from The College Survey for Students with Brain Injury (CSS-BI) were investigated with adults with and without traumatic brain injury (TBI). Methods: Adults with and without TBI completed the CSS-BI. A sub-set of participants with TBI were interviewed, intentional and convergent validity were investigated, and the internal structure of the college challenges was analysed with exploratory factor analysis/principle component analysis. Results: Respondents with TBI understood the items describing college challenges with evidence of intentional validity. More individuals with TBI than controls endorsed eight of the 13 college challenges. Those who reported more health issues endorsed more college challenges, demonstrating preliminary convergent validity. Cronbach’s alphas of 40.85 demonstrated acceptable internal reliability. Factor analysis revealed a four-factor model for those with TBI: studying and learning (Factor 1), time management and organization (Factor 2), social (Factor 3) and nervousness/anxiety (Factor 4). This model explained 72% and 69% of the variance for those with and without TBI, respectively. Conclusion: The college challenges sub-set from the CSS-BI identifies challenges that individuals with TBI face when going to college. Some challenges were related to two factors in the model, demonstrating the inter-connections of these experiences.

Academics, cognition, college, post-secondary

Introduction Many individuals with traumatic brain injury (TBI) return or go on to college after being injured. For those who have sustained moderate or severe initial injuries, advances in early acute intervention and rehabilitation mean that many recover such that succeeding in college is a very real possibility for civilians, veterans and active duty service military. Service members returning from the recent wars can use the 9/11 GI bill to fund their college education, while civilian adolescents and young adults with mild TBI return to high school or college as symptoms are being managed. Although strides have been made in transitioning individuals back to school after TBI [1, 2], research to date lacks descriptions of the everyday challenges these students experience. One main reason for this is the absence of psychometrically valid and reliable questionnaires or surveys that address post-secondary challenges. Given the importance of person-centred outcomes, these kinds of tools provide important information about how individuals view their problems, a first step in determining practical educational and rehabilitation goals [3]. Correspondence: Mary R. T. Kennedy, PhD, Professor, Communicative Sciences & Disorders, Chapman University, One University Dr., Orange, CA 92866, USA. Tel: 714-744-2132. Fax: 714-744-7035. E-mail: [email protected]

History Received 8 November 2013 Revised 30 June 2014 Accepted 2 August 2014 Published online 29 September 2014

The purposes of this study were (1) to examine the psychometric properties of a survey, The College Survey for Students with Brain Injury (CSS-BI) [4], which was designed to describe the challenges college students face after TBI, and (2) to compare these challenges to those reported by individuals without TBI. The ultimate goal is to provide researchers and clinicians with a sound evaluation tool with which they can gain a better understanding of the practical and relevant needs of these individuals, the kind of support that is needed and a way to measure change. The CSS-BI [4] was developed to capture how individuals describe their general health effects (cognitive, psychosocial and physical) and academic or ‘college’ challenges around studying and learning, time management and social relations after TBI. The CSS-BI contains two sub-sets of items that describe general health effects and college challenges. Sixteen general health effects are listed in the survey and respondents provide ‘yes’ or ‘no’ responses to indicate whether they had experienced each effect after their injury. Commonly associated symptoms after TBI are listed, including cognitive, physical and psychosocial issues. In the college challenges section, 13 statements are listed. Respondents rate their level of agreement with each statement using a 5-point Likert rating scale ranging from strongly disagree (1) to strongly agree (5).1 This bank of challenges was intended to primarily reflect the

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practical effect on everyday activities of common cognitive impairments such as attention, new learning, information processing in and outside of class and planning and organization and other executive functions [5–10]. Because psychosocial activities play an important role in college life for all students, including those with disabilities [11], items on the CSS-BI were included that ask about having friends and being nervous or anxious. In studies by Dawson et al. [12, 13], cognitive and psychosocial factors were significantly related to ‘return to productivity’, which was defined as paid employment or school attendance. Logistic regression of neuropsychological, physical, psychological, spiritual and environmental measures revealed that the amount of time to regain free recall, severity of neuropsychological status, the presence of maladaptive coping strategies and pain (which correlated with depression) significantly predicted productivity. Additionally, the authors of the CSS-BI also drew on their clinical experiences working with college students with TBI to identify common college challenges for inclusion on the survey [4]. Individuals currently enrolled and who had been in college after TBI provided interview feedback on the validity and wording for finalizing these items. It was important to capture a wide range of challenges that could reflect underlying cognitive and psychosocial constructs associated with TBI, particularly for those whose recovery has been sufficient to attempt college. Initially, Kennedy et al. [5] used the CSS-BI to descriptively report the survey results of 35 adults who had attended college after TBI. They found that those who reported a greater number of health effects were also more likely to endorse more college challenges, e.g. reviewing material more, being overwhelmed in class and forgetting what is said in class. It was the cognitive health effects that best predicted the number of challenges, accounting for 46% of the variance. Psychosocial effects also contributed significantly to the variance, accounting for 16% of the variance, whereas physical effects contributed little. In 2012, Mealings et al. [14] reviewed the literature examining students’ perspectives on returning to school after brain injury. A variety of methods were used, including questionnaires and interviews. Four broad areas of difficulty were encountered: cognitive, psychosocial, emotional and physical. For example, life and cognitive changes, such as reducing course load, using more effort and getting overwhelmed in class, were themes across studies. The importance of psychosocial issues also became apparent, constituting a critical aspect that should be considered. Unfortunately, only two of the studies focused exclusively on post-secondary education [5, 15]. Hux et al. [15] used a convenience sample of participants known to the researchers, whereas the Kennedy et al. [5] study was on-line and anonymous. Serious limitations pointed out by Mealings et al. [14] included the low number of studies that used self-report and the lack of evaluation tools or protocols. A recent study by Willmott et al. [16] provided additional evidence about the challenges these students face. Participants who had returned to secondary or post-secondary school after brain injury were followed for 10 years. Many changed their course of study, switched to part-time status and received

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accommodations. Students reported being relatively successful, but also reported that it was difficult to keep up and to learn. They reported expending more ‘effort’ to be successful, while at the same time, were less satisfied with their performance. Similar to findings of Kennedy et al. [5], memory, concentration, irritability and fatigue were the most commonly reported symptoms, while fewer participants reported being ‘socially isolated’. The results from this study were combined across secondary and post-secondary students, making is impossible to assess the results from each group alone. Clearly the field is in need of a measurement tool specifically designed for those going to college after brain injury. Using the CSS-BI [4] serves this need by providing a unique window into the perspectives of a large sample of postsecondary students with brain injury. The brevity and ease of administration of the CSS-BI also offers an opportunity to capture the perspectives of students who were injured after completing secondary education and, therefore, not identified by a school system prior to transitioning to college. However, without documenting the psychometric properties of the CSS-BI, clinicians and researchers would be uncertain about the reliability and validity of responses. Therefore, the purpose of this preliminary study was to document psychometric properties of a sub-set of the CSS-BI that lists challenges experienced in college. To do this, this study (1) compared the health issues and college challenges reported by adults with and without TBI and (2) assessed aspects of the survey’s construct validity, reliability and internal structure (i.e. dimensionality).

Methods General procedures The CSS-BI was disseminated electronically by posting its Survey Monkey link in electronic newsletters associated with state-level brain injury organizations, researcher and clinician websites and campus disability services. To recruit adults without TBI, ads explicitly requested ‘friends and family members of adults with TBI who had attended college’. Respondents were also recruited through announcements in undergraduate college courses. The first page of the survey was the consent form, which respondents read and ‘signed’. Comprehension questions were asked at the end of the consent page to determine if respondents understood the purpose and elements of the survey. Data were discarded if respondents indicated that they did not have authority to sign legal documents. Participants had the opportunity to participate in a $30 Amazon.com gift card drawing. The Institutional Review Board for Human Subjects at the University of Minnesota approved all procedures. The college survey for students with brain injury The CSS-BI used in the 2008 study [5] was completely anonymous; a revision of the survey in 2009 [4] included age and education information. Furthermore, in the 2009 version, the two sub-sections considered in this analysis were modified for respondents without brain injury, i.e. controls. ‘Effects of Brain Injury’ (What have been

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some effects of your brain injury?) was modified for controls to be called ‘Health Challenges’ (Have you experienced or did you experience any of these conditions while in college?). In all versions, respondents were instructed to ‘Check all that apply, and indicate whether you have ever received therapy for each effect’. The items within each sub-set were fully randomized for each respondent and the headings (cognitive, physical/medical, psychosocial) were not on the survey itself. This health sub-set was included in the current analysis so as to describe the sample populations and to preliminarily examine construct validity of the list of college challenges in ‘Your Student Challenges’ described in the paragraph below. The other sub-set of items, called ‘Your Student Challenges’ (To what extent do you agree with each of the following statements about your experience as a college student since your brain injury?) was revised to ‘Your College Challenges’ for controls (To what extent do you agree with each of the following statements about your experience as a college student?). For this sub-set, respondents rated their agreement using a 5-point Likert rating scale (1 ¼ strongly disagree, 2 ¼ disagree, 3 ¼ neither agree nor disagree, 4 ¼ agree, 5 ¼ strongly agree). Data collection and respondents Data were initially published based on anonymous surveys from 35 adults with TBI [5]. Shortly after this, the CSS-BI was modified for those without TBI and additional data were collected. In 2010, age and years of education were added to the survey and data were collected on both groups. The rationale behind this progressive data collection was that if results from the sequential sub-groups were similar, then they could be combined into larger samples. One could also compare the population samples across groups (TBI, controls) to make sure they were similar in age and education. Exclusion criteria consisted of having other neurological conditions (e.g. stroke) and, for controls, the presence of seizures. The final total sample of 48 adults with TBI included a sub-group of 13 for whom demographic information was collected. Sixty-two controls completed a modified CSS-BI (described below), of which seven were excluded. The final sample of 55 controls included a demographic subgroup of 21. Demographic and non-demographic sub-groups with TBI were compared to determine whether they were sufficiently similar to collapse into a larger sample. Comparisons included

whether the injury occurred after the age of 18, length of loss of consciousness, length of hospital stay and use of rehabilitation services (see Table I). None of these comparisons approached statistical significance (p  0.05); thus, data from the two TBI sub-groups were combined into a single sample (n ¼ 48). Furthermore, age did not differ between the combined TBI group and the control demographic subgroup (p  0.05). Diagnostic and injury information from the TBI demographic sub-group was confirmed by reviewing medical records (see Table II). Loss of consciousness (LOC) was consistently documented in the medical record, although the LOC amount of time was not. Nine respondents had severe injuries, two had moderate–severe injuries and two had mild injuries. Interviews Individuals in the demographic sub-group with TBI were interviewed to verify survey responses and verify that they understood the intent of the 13 statements about academic challenges. The latter is called ‘intentional validity’. The first author conducted the interviews and read each statement aloud along with the rating the respondent had provided. For example, the interviewer said, ‘. . . the next one is ‘‘I get overwhelmed in class’’ and you said that you agreed with this. Is that correct? And can you tell me more about this?’ All interviews were audio recorded and transcribed word for word. Statements were coded twice; first to verify their rating and, second, to assess whether the additional information provided in response to ‘And can you tell me more about this?’ indicated that they had interrupted the statement as intended. Three research assistants independently verified respondents’ levels of endorsement and that, based on the additional interview responses, respondents interpreted statements correctly.

Results Comparisons between TBI and control groups Health effects2 Table III lists the number and percentages from each group who reported each health effect. A majority but not all of those with TBI reported having experienced the cognitivebehavioural difficulties (e.g. memory problems, difficulty with academics, organization problems), psychosocial difficulties (e.g. anger, depression) and physical problems

Table I. Demographic information for TBI and control groups. TBI (48)

Number Age Education TPO (years) Age at injury 418 LOC (in days) Length of hospital stay Received rehabilitation Days in rehabilitation

Controls (55)

Demographic

Non-demographic

Demographic

Non-demographic

13 27.62 (12.74) 14.23 (1.49) 4.17 (7.19) 92.31% 17.67 (19.59) 54.56 (36.57) 92% 263 (118)

35 – – – 71.40% 25.00 (31.70) 80.00 (96.3) 80% 202 (141.2)

21 25.71 (12.75) 14.84 (2.01) na na na na na na

34 – – na na na na na na

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Table II. Injury information on demographic sub-group of TBI respondents. Participant

Type of injury

1

Sports injury

2 3 4

Fall Fall Vehicular accident

5 6

Vehicular accident Sports injuries & fall

7

Vehicular accident

8

Vehicular accident

9

Vehicular accident

10

Fall

11

Vehicular accident

12

Vehicular accident

13

Vehicular accident

Neuropathology and Injury information

Severity of injury

R frontal, base and facial skull fractures with frontoparietal epidural and subdural haematomas, R frontal craniotomy; LOC No neuropathological evidence, but documented TBI diagnosis L frontal contusion with temporoparietal subdural haematoma; LOC L thalamus and internal capsule haemorrhage, small but deep thalamic/basal ganglia haematoma; LOC L frontotemporal haematoma with craniectomy; LOC No visible neuropathology; four mild TBIs or concussions with 45 minute LOC during one; unresolved post-concussion symptoms R frontal & basal skull fractures subdural haematoma and craniectomy, encephalomalacia R parietal, frontal, & temporal lobes, R subdural haematoma, documented LOC Medical records unavailable; self- & family-reported LOC for several weeks; acute hospitalization & in-patient rehabilitation confirmed DAI L temporal and occipital lobes, subdural haematoma, repeat MRI showed post-traumatic encephalomalacia in the posterior frontal, temporal, & right occipital lobes and adjacent subcortical white matter and upper brainstem Medical records unavailable; self-report LOC for weeks, acute hospitalization and in-patient rehabilitation confirmed Diffuse intraparenchymal oedema and subarachnoid haemorrhage, cranial nerve damage, LOC Scattered foci of abnormal intensity consistent with DAI, probable additional infarct, LOC Bifrontotemporal subdural hygromas, subarachnoid haemorrhage, DAI, contusions bifrontal regions, L cerebellar hemisphere, LOC

Moderate-to-severe Mild Severe Severe Severe Multiple mild TBIs Moderate-to-severe Severe Severe

Severe Severe Severe Severe

LOC, loss of consciousness; DAI, diffuse axonal injury.

Table III. Number and percentage of individuals with TBI (n ¼ 48) and without TBI (n ¼ 55) who reported these health effects while in college, including the rankings by group. TBI n (%) Cognitive* Memory problems Difficulty with academics Organization problems Problems making decisions Attention problems Physical/Medical* Dizziness Fatigue Headaches Physical impairment: legs (e.g. walking), dizziness Physical impairment: arms/hands (e.g. writing) Psychosocial* Anger Depression Mood changes Difficulty with relationships Difficulty maintaining friendships Substance/alcohol abuse

Controls

Ranking

n (%)

Ranking

41 37 34 31 32

(85%) (77%) (71%) (65%) (67%)

1 2 4 6 5

14 19 16 10 22

(25%) (35%) (29%) (18%) (40%)

9 6 7 10 4

21 35 27 30

(44%) (73%) (56%) (63%)

10 3 8 7

16 30 21 1

(29%) (55%) (38%) (2%)

7 1 5 12

17 (35%)

11

Chi-square analyses were conducted to determine if groups differed in the total number of health effects. As expected, respondents with TBI reported more overall health problems across cognitive, physical and psychosocial categories (M ¼ 9.19, SD ¼ 3.35) than controls (M ¼ 4.48, SD ¼ 3.72), 2(2, n ¼ 103) ¼ 39.49, p ¼ 0.001. Specifically, respondents with TBI endorsed more cognitive (M ¼ 3.65, SD ¼ 1.51), physical (M ¼ 2.71, SD ¼ 1.29) and psychosocial issues (M ¼ 2.83, SD ¼ 1.69) than controls (cognitive, M ¼ 1.47, SD ¼ 1.60; physical, M ¼ 1.25, SD ¼ 1.17; psychosocial, M ¼ 1.75, SD ¼ 1.61). All of these comparisons were statistically significant: cognitive, 2(2, n ¼ 103) ¼ 34.55 p ¼ 2  107; physical, 2(2, n ¼ 103) ¼ 31.04, p ¼ 9  107; psychosocial, 2(2, n ¼ 103) ¼ 11.43, p ¼ 0.043). College challenges

31 32 32 22 16

(65%) (67%) (67%) (46%) (33%)

3 (6%)

6 5 5 9 12 13

1 (2%) 16 23 28 15 10

(29%) (42%) (51%) (27%) (18%)

4 (7%)

12 7 3 2 8 10 11

*Category labels are not shown when taking the survey and items are randomized.

(e.g. fatigue, headaches). In contrast, fatigue and mood changes were the only items reported by a majority of controls, followed by depression. The cognitive problems reported by adults with TBI were endorsed by far fewer controls.

The total number of college challenges that respondents endorsed (agreed or strongly agreed) was also compared between groups (see Table IV). Out of the 13 statements about college challenges, respondents with TBI endorsed significantly more (M ¼ 6.90, SD ¼ 3.22) than controls (M ¼ 3.67, SD ¼ 2.81), 2(2, n ¼ 103) ¼ 29.06, p ¼ 0.004. The majority of respondents with TBI (59%) agreed (or strongly agreed) that others do not understand their problems, whereas only 13% of controls agreed. Having fewer friends was endorsed by 46% of respondents with TBI, whereas 22% of controls agreed. Respondents with TBI were also more likely to agree than controls with statements about having to review material more (94%, vs. 31% of controls), forgetting what is said in class (52%, vs. 20% of controls), difficulty understanding instructions (48%, vs. 20% of controls), being overwhelmed in class (37%, vs. 18% of controls)

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Table IV. College challenges sub-set: The number and percentage of individuals with TBI (n ¼ 48) and without TBI (n ¼ 55) by endorsement ratings. Ratings Groups Statements* I have to review material more than I used to (TBI) or I have to review material a lot (controls). I get nervous before tests. I don’t always understand instructions for assignments. I forget what has been said in class. I get overwhelmed when studying. I get overwhelmed in class. I am late to class. I have trouble prioritizing assignments and meeting deadlines. I have trouble managing my time. I have fewer friends than before (TBI) or I have fewer friends than I thought I would have (control). I have trouble paying attention in class or while studying. I procrastinate on things I need to do. Others do not understand my problems.

Strongly disagree (1)

Disagree (2)

Neither (3)

TBI

Control

Strongly agree (5)

TBI

Control

TBI

Control

TBI

1 (2%)

6 (11%)

1 (2%)

15 (27%)

1 (2%)

2 (4%) 2 (4%)

8 (15%) 13 (24%)

1 (2%)

9 (16%)

7 (15%) 19 (35%) 10 (21%) 16 (29%) 20 (42%) 10 (18%) 10 (21%)

1 (2%)

1 (2%)

7 (13%)

9 (19%) 15 (27%)

8 (17%)

4 (7%)

5 (10%) 18 (38%) 6 (13%)

14 (25%) 20 (36%) 13 (24%)

7 (13%) 15 (31%) 10 (18%) 7 (13%) 4 (8%) 3 (5%) 7 (13%) 12 (25%) 5 (9%)

3 (6%) 1 (2%) 7 (15%)

0 1 (2%) 1 (2%)

4 (8%)

9 (16%)

8 (17%) 19 (35%) 13 (27%) 12 (22%) 14 (29%) 14 (25%)

9 (19%)

1 (2%)

7 (15%)

19 (35%)

9 (19%) 20 (36%) 10 (21%)

15 (31%) 10 (18%)

7 (15%)

2 (4%)

5 (10%)

6 (11%)

8 (17%) 18 (33%)

9 (19%) 10 (18%) 19 (40%) 19 (35%)

7 (15%)

2 (4%)

7 (15%)

2 (4%)

10 (21%) 13 (24%)

4 (8%)

6 (11%) 18 (38%) 24 (44%)

9 (19%) 10 (18%)

1 (2%)

12 (22%)

5 (10%) 28 (51%)

8 (17%)

8 (15%) 22 (46%)

6 (13%) 10 (18%) 12 (25%) 11 (23%) 24 (44%) 12 (25%)

Control

Agree (4)

Control

17 (31%) 22 (46%) 16 (29%) 23 (48%)

5 (9%) 20 (42%) 22 (40%) 7 (13%) 15 (31%) 11 (20%)

7 (15%) 11 (20%) 23 (48%) 18 (33%)

8 (17%) 24 (44%) 17 (35%) 10 (21%) 24 (44%) 15 (31%) 15 (31%) 29 (53%) 8 (17%)

TBI

4 (7%)

1 (2%)

8 (17%) 10 (18%) 8 (17%) 0

7 (13%) 12 (25%)

0

*Statements were fully randomized for each individual. Table V. College challenges sub-set: Means and standard deviations of ratings provided by those with TBI and controls without TBI.

I have to review material more than I used to (TBI) or I have to review material a lot (control). I get nervous before tests. I don’t always understand instructions for assignments. I forget what has been said in class. I get overwhelmed when studying. I get overwhelmed in class. I am late to class. I have trouble prioritizing assignments and meeting deadlines. I have trouble managing my time. I have fewer friends than before (TBI) or I have fewer friends than I thought I would have (control). I have trouble paying attention in class or while studying. I procrastinate on things I need to do. Others do not understand my problems.

and having trouble prioritizing (40%, vs. 11% of controls). Forty-eight per cent of those with TBI and 27% of controls endorsed trouble managing their time. Sixty-five per cent of those with TBI and 40% of controls endorsed being overwhelmed when studying, whereas 55% of those with TBI and 39% of controls endorsed trouble paying attention in class or while studying. More controls (62%) than those with TBI (57%) agreed that they procrastinate and nearly no respondents in either group endorsed being late to class (10% TBI, 7% controls). Thus, with the exception of the last two items, more

TBI M (SD)

Control M (SD)

p Value

4.35 (0.81)

2.84 (1.03)

0.0000000000008

3.54 3.33 3.65 3.58 3.06 2.17 2.98 3.33 3.13

3.29 2.29 2.55 2.95 2.24 1.93 2.13 2.62 2.20

0.30 0.000005 0.0000005 0.005 0.0001 0.24 0.0002 0.002 0.0003

(1.05) (1.14) (1.04) (1.05) (1.08) (1.10) (1.30) (1.21) (1.30)

3.31 (1.22) 3.25 (1.38) 3.81 (1.00)

(1.36) (1.05) (1.03) (1.19) (1.04) (0.94) (0.94) (1.10) (1.21)

2.87 (1.12) 3.49 (1.15) 2.18 (0.93)

0.06 0.34 0.0000000000001

respondents with TBI endorsed these college challenges than did those without TBI. To identify differences in the level of endorsement, planned comparisons were conducted of the ratings that each group made (see Table V), with higher ratings indicating stronger endorsement. Overall, the ratings by respondents with TBI were higher than controls. With a 0.05 p value criterion adjusted to 0.004 for multiple comparisons, eight comparisons remained statistically significant. ‘I get overwhelmed when studying’ fell just outside the significant range

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(p ¼ 0.005), whereas endorsement of ‘I get nervous before tests’, ‘I am late to class’, ‘I have trouble paying attention in class or while studying’ and ‘I procrastinate on things I need to do’ did not differ between groups. Validity of college challenges Intentional validity Transcripts from the interviews of 13 adults with TBI were used to determine intentional validity. A total of 190 interview responses were independently coded from transcriptions. Of these, 183 statements indicated that respondents verbally agreed with their written survey ratings, i.e. 96.32% agreement or intra-rater reliability. Coders also identified whether or not respondents provided additional information when questioned about the statement as a way to determine if the statement had been interpreted as intended. Based on this assessment, intentional validity was 98.25%, indicating that respondents had interpreted items as they were intended. Relationships between health effects and college challenges It was expected that those who reported more health issues would endorse more college challenges, providing preliminary evidence of construct validity for the CSS-BI. Convergent validity, a type of construct validity, is the extent to which two measures that are theoretically related are indeed related in a given sample. To measure convergent validity, regressions were conducted to determine if the number of endorsed health effects predicted the number of endorsed college challenges. For those with TBI, the total number of health issues significantly predicted the number of endorsed college challenges and accounted for 29% of the variance [r2 ¼ 0.29, F(1, 47) ¼ 18.53, p ¼ 0.000]. Specifically, the number of cognitively related health issues significantly predicted the number of endorsed college challenges and accounted for 50% of the variance [r2 ¼ 0.50, F(1, 47) ¼ 46.67, p ¼ 0.000], whereas physical health issues did not predict college challenges and accounted for only 4% of the variance [r2 ¼ 0.04, F(1, 47) ¼ 1.87, p ¼ 0.18]. The number of psychosocial health effects tended to predict the number of college challenges, accounting for 7% of the variance [r2 ¼ 0.07, F(1, 47) ¼ 3.84, p ¼ 0.056]. Similar to those with TBI, the total number of reported health issues significantly predicted the number of college challenges reported by controls, accounting for 25% of the variance [r2 ¼ 0.25, F(1, 54) ¼ 17.95, p ¼ 0.000]. The number of cognitively related health issues significantly predicted the number of college challenges and accounted for 19% of the variance [r2 ¼ 0.19, F(1, 54) ¼ 12.70, p ¼ 0.001], the number of endorsed physical issues [r2 ¼ 0.15, F(1,54) ¼ 9.55, p ¼ 0.003] accounted for 15% of variance and the number of psychosocial health issues accounted for 19% of the variance [r2 ¼ 0.19, F(1,54) ¼ 12.66, p ¼ 0.001]. Internal structure of the CSS-BI college challenges sub-set The internal structure of the 13-item college challenges sub-set was examined separately by group because: (1) groups

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differed in their endorsement of the college challenges and (2) the challenges were intended to capture the challenges of those with TBI and not those without TBI. Thus, the internal structure, or how these challenges are inter-related, could vary by group. Using the endorsement ratings, Pearson correlation matrices were generated. For those with TBI, 43 significant interitem relationships were found and 48 significant relationships were found for controls (p  0.05). Therefore, the reliability and dimensionality of this sub-set of items needed further exploration. Cronbach’s alpha was used to examine internal reliability, i.e. how closely items are related to each other based on a unifying construct. High alpha coefficients of 0.70 indicate that items are highly reliable. Cronbach’s alpha was 0.86 for those with TBI and 0.85 for controls. Thus, there was high internal consistency among the 13 statements, regardless of TBI. Item-total statistics and scaled variance were examined to determine if any items should be eliminated. Reductions of the total variance were revealed if any one of the 13 items were eliminated; for those with TBI, the variance would be reduced to 79.92% (from 86%) and for controls, the variance would be reduced to 73.10% (from 85%). Furthermore, the scaled variance accounted for by the remaining 12 items was substantially reduced: from 86% for those with TBI to a range (depending on the item eliminated) of 62.96–74.21% and from 85% for controls to a range of 59.24–69.03%. Thus, all 13 items were retained for factor analysis modelling. Exploratory factor analysis with varimax rotation provides an understanding of the dimensionality of these 13 college challenges by reducing ‘the common variance. . . to a smaller number of conceptually meaningful variables and to understand how each basic unity (i.e. tests or items) is structured’ ([17], p. 415). Data were transformed into orthogonal variables using all three types of variance (i.e. common, specific and error) and employing principle component analysis (PCA). Eigenvalues of 1.0 for each factor are typically considered strong and any item that loads onto factors at 0.40 are considered strongly loaded. For the purposes of this paper, items that loaded at 0.60 are described as ‘very strong’ and items that loaded 50.60 but 0.40 as ‘strong’. Table VI contains the results of the exploratory factor analysis of the self-reported endorsement ratings for each group for each of the 13 college challenges. A four-factor model explained 71.98% and 68.67% of the total variance for those with TBI and controls, respectively. For those with TBI, factor 1 accounted for 23.28% of the total variance, factor 2 accounted for 22.62%, factor 3 accounted for 14.70% and factor 4 accounted for 11.43%. Nine items loaded onto single factors, four items loaded onto two factors and no items loaded onto three or four factors. The model for controls revealed a similar distribution of the explained variance: factor 1 accounted for 24.84% of the total variance, factor 2 accounted for 21.14%, factor 3 accounted for 13.77% and factor 4 accounted for 8.91%. Furthermore, nine items loaded onto a single factor, four items loaded onto two factors and no items

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Table VI. College challenges sub-set: Factor eigenvalues and individual item loadings for groups with and without TBI using varimax rotation. TBI model with eigenvalues Factor 1 3.02 I have to review material more than I used to. (TBI); I have to review material a lot. (control) I get nervous before tests. I don’t always understand instructions for assignments. I forget what has been said in class. I get overwhelmed when studying. I get overwhelmed in class. I am late to class. I have trouble prioritizing assignments and meeting deadlines. I have trouble managing my time. I have fewer friends than before. (TBI); I have fewer friends than I thought I would have (control). I have trouble paying attention in class or while studying. I procrastinate on things I need to do. Others do not understand my problems.

Control model with eigenvalues

Factor 2 2.94

Factor 3 1.91

Factor 4 1.49

Factor 1 3.20

Factor 2 2.75

Factor 3 1.91

Factor 4 1.16

0.750

0.046

0.079

0.214

0.673

0.040

0.306

0.428

0.166 0.771

0.019 0.231

0.049 0.040

0.865 0.070

0.847 0.758

0.093 0.231

0.066 0.232

0.045 0.041

0.745 0.476 0.701 0.132 0.446

0.045 0.296 0.391 0.704 0.708

0.344 0.160 0.070 0.473 0.081

0.200 0.604 0.203 0.161 0.148

0.475 0.766 0.584 0.013 0.176

0.178 0.218 0.321 0.177 0.768

0.598 0.235 0.489 0.022 0.064

0.134 0.031 0.105 0.901 0.267

0.032 0.166

0.831 0.132

0.179 0.819

0.208 0.238

0.072 0.139

0.801 0.158

0.065 0.880

0.186 0.027

0.532

0.607

0.212

0.206

0.274

0.664

0.327

0.117

0.177

0.734

0.334

0.059

0.062

0.775

0.260

0.070

0.013

0.174

0.814

0.216

0.443

0.418

0.17

0.072

Note: Italicized values represent items that loaded 0.40 onto that factor.

loaded onto three or four factors. However, some of the items loaded onto different factors for those without TBI compared to those with TBI. A summary and preliminary interpretation of these relationships are provided in the discussion below.

Discussion The purpose of this study was to document the preliminary psychometric properties of a sub-set of the CSS-BI that lists 13 college challenges that one could experience after TBI. These were intended to reflect cognitive impairments and psychosocial issues that college students with TBI experience [4]. Indeed, prior research has shown that cognitive and psychosocial issues predict lower productivity [5, 13, 14, 16, 18]. Thus, this study compared the health effects and college challenges of those with TBI to those without TBI, examined construct validity and explored inter-item relationships to investigate the internal structure (i.e. dimensionality) of the college challenges. Health effects and college challenges: Differences between those with and without TBI Those with TBI reported more health issues while in college than those without TBI. The cognitive issues listed on the CSS-BI [4] are ubiquitous with TBI and supported by decades of research and clinical literature. Indeed, more than 65% of individuals with TBI endorsed the cognitive health problems, while less than 40% of controls endorsed these problems. Of the physical problems, fatigue was endorsed by just over half of controls vs. a clear majority by those with TBI. This is

consistent with studies that report that college students report high levels of fatigue [19], but also that fatigue is a predominant complaint of individuals with TBI [20, 21] and correlates with stress [22]. With regards to psychosocial issues, more individuals with TBI endorsed these than controls, consistent with studies that have found higher reports of depression and anxiety after injury [23, 24]. It should also be noted that the percentage of controls who endorsed depression is slightly higher than current projections [25], but that other mental health issues reported by controls were lower than the national average of nearly 50% in the US [26]. The higher percentage of individuals with TBI reporting difficulty with relationships is also consistent with reports of loss of friends and other relationships after TBI [27, 28]. Like the health effects, more individuals with TBI than controls endorsed statements that described college challenges. Consistent with prior studies that students have to study more after TBI [14, 16], a majority of individuals with TBI in the current project endorsed a variety of learning and studying challenges for which the degree of endorsement was higher than controls. These included reviewing material more, forgetting what is said in class, being overwhelmed when studying and having trouble paying attention. The biggest differences in the degree of endorsement between the two groups related to the social part of being in college, included in statements about relationships [29]. Some of the statements yielded similar levels of endorsement regardless of TBI. Being nervous before tests, being late to class, procrastinating and having trouble paying attention are common complaints of college students. Reports of

DOI: 10.3109/02699052.2014.955883

college student behaviour show relationships between behaviour and psychological characteristics. For example, procrastination is associated with higher anxiety [30] in typical college students. All college students regardless of TBI clearly reported some challenges, but the way in which the challenges interact may vary by group, as demonstrated by differences in the two factor models. It is also important to observe that individuals with TBI did not endorse all of the health issues or college challenges; furthermore, controls did not claim to be free of these effects or challenges either. Both the health effects and college challenges are presented in the CSS-BI as ‘problems’. Health issues were presented as a list, whereas college challenges were presented as ‘negative’ statements, with respondents rating their level of agreement. Over-endorsement of symptoms by individuals with health conditions can be a concern; however, the results showed a range of endorsement from those with TBI. For example, while only 6% indicated that they were unsure or did not review material more (since their injury), 90% disagreed or were unsure that they were ‘late to class’. Of the other 11 college challenges, those who disagreed or were unsure ranged from 29% for ‘others do not understand my problems’ to 61% for ‘I have trouble prioritizing assignments and meeting deadlines’. Validity of college challenges Intentional validity or the verification of responses to college challenges was examined by interviewing the sub-set of respondents with TBI for whom demographic information was available. High levels of agreement indicated that respondents confirmed their survey responses with verbal responses; thus, the college challenges were interpreted as the authors intended. Convergent validity describes the extent to which an instrument measures what it is suppose to measure and is typically related to some underlying theory. Here, only preliminary evidence of this is provided given that the health issues sub-set was used to predict the college challenges, both from the CSS-BI. The number of endorsed health effects was related to the number of endorsed college challenges for both groups. Those who endorsed more health issues also endorsed more college challenges. For those with TBI, half of the variance from college challenges was accounted for by the cognitive-related health issues, with much less explained by psychosocial issues and none explained by physical issues. This finding is consistent with prior reports that cognitive impairments predict the ability to return to work or school [13]. In a smaller sample by Kennedy et al. [5], cognitive impairments best predicted the number of college challenges endorsed by people with TBI, followed by psychosocial issues, whereas physical impairments did not account for college challenges. Given the dimensionality of the college challenges discussed below, these results make sense since most of the challenges are academically related. For uninjured controls, there was a more equal distribution of the variance from college challenges explained by cognitive, physical and psychosocial health issues. This may be

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related to the finding that fewer controls endorsed these health issues overall and those that were endorsed differed from those with TBI. For example, over half of controls endorsed fatigue (a physical problem) and mood changes (a psychosocial problem), which are common complaints of college students in general [26]. Regardless, a fair amount of variance was unexplained by the health issues on the CSS-BI for either group. Internal structure of the college challenges sub-set The internal structure of the college challenges sub-set was examined using respondents’ 1–5 Likert ratings of agreement. Ratings from each group were highly related, indicated by Cronbach’s alpha 0.70. Inter-item correlations were also examined and there were more than 40 significant relationships for each group. An exploratory four factor model of the college challenges explained similar amounts of variance for those with (72%) and without TBI (69%). Groups were similar in the number of challenges loading on to singular or multiple factors: nine items loaded on to a single factor, four items loaded onto two factors and no items loaded onto three or four factors. In general, the loadings for those with TBI were as anticipated, given that these challenges were intended to represent the practical expressions of cognitive impairments and psychosocial issues in college. What was not known a priori was the degree to which items would cluster or load on to factors and which items would load onto multiple factors. Nor was it known how responses from controls would be related. Factor 1 appears to be related to studying and learning both in and outside of the classroom, irrespective of TBI. The two groups shared five college challenges that loaded onto this factor: reviewing material more, not understanding instructions, forgetting what has been said, being overwhelmed when studying and being overwhelmed in class. These challenges share underlying constructs of understanding and remembering, which is also related to feelings of being overwhelmed. If feeling overwhelmed means feeling anxious, then this could provide tangible, explicit evidence of links between anxiety and learning, both reported by those with and without TBI. For example, Spitz et al. [31] recently reported that greater cognitive impairment predicted greater anxiety and depression, regardless of severity of TBI. Two items that include the word ‘overwhelmed’ loaded onto factor 1; while ‘overwhelmed in class’ loaded solely onto factor 1, ‘overwhelmed while studying’ also loaded onto factor 4, nervousness or anxiety. It is also important to notice that, for those with TBI, ‘trouble prioritizing and meeting deadlines’ and ‘trouble paying attention in class or while studying’ loaded onto factor 1, but also loaded more strongly onto factor 2, time management and organization. These shared loadings demonstrate the relatedness of these challenges: prioritizing, paying attention and being overwhelmed are all related and therefore share some underlying construct(s) that links executive functions of planning and attending to emotions. This is consistent with the authors’ clinical experience working with college students with TBI; that those who report learning and studying challenges

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frequently report feeling overwhelmed and have trouble prioritizing and meeting deadlines. Unlike those with TBI, two additional challenges loaded onto factor 1 for controls. Fifty-eight per cent reported being nervous before tests and this item loaded very strongly on studying and learning, along with the other five items discussed above. ‘Others do not understand my problems’ was also related to this factor; however, only 13% endorsed this experience and it shared relatedness with factor 2, time management and organization. For these individuals, being ‘nervous before tests’ was strongly related to other studying and learning challenges, but this was not the case for those with TBI. Thus, both groups appear to share some cognitive constructs underlying factor 1, studying and learning, but other aspects such as being nervous or overwhelmed may be related in different ways to studying and learning challenges across groups. For factor 2, there were four challenges that both groups shared: ‘trouble managing time’, ‘trouble prioritizing assignments and meeting deadlines’, ‘trouble paying attention in class or while studying’ and ‘procrastinating on things I need to do’. These appear to be related to executive functions used to generate goals and plans and to exert executive control over attention and behaviour and can be called time management and organization. For those with TBI, ‘I am late to class’ was related to this factor. For controls, ‘others do not understand my problems’ was related to this factor in addition to study and learning. Factors 3 and 4 accounted for less of the groups’ variance, but still contributed to each model. Having fewer friends than before (for TBI) or than expected (for controls) was very strongly loaded on to factor 3, the social factor. For those with TBI, this was also associated with the experience of others not understanding their problems, which makes intuitive sense. ‘Being late to class’ loaded negatively onto social, but positively on time management and organization. The former may not seem logical at first but is consistent with our experiences with students with TBI. In interviews, most report that being on time to class is a way to be prepared and ready to learn. These students also report that their peers do not understand what it takes for them to be able to succeed in college and one aspect of this is being to class on time. For controls, the social factor was defined by ‘having fewer friends’, while ‘in class’ challenges of forgetting and being overwhelmed were also related. It is possible that the underlying construct here is psychosocial. However, these two challenges were also related to studying and learning. While it is not known with certainty what ties these three challenges together, it appears that there is a different social construct than for those with TBI, for whom the factor strongly ties together having fewer friends with others not understanding their problems and not being late to class. As anticipated for those with TBI, factor 4 was defined by being ‘nervous before tests’ and ‘overwhelmed when studying’. Because of this, this factor is called ‘nervousness or anxiety’. Being overwhelmed when studying was also strongly associated with studying and learning. This was not the case for controls; being ‘late to class’ and ‘reviewing material a lot’ was associated with this fourth factor. It is challenging to

Brain Inj, 2014; 28(13–14): 1748–1757

conceptualize an underlying construct for these two experiences that is not cause/effect for controls. That is, when students are late to class, they have to review missed material. Regardless, this factor was not the same across groups.

Conclusions, limitations and clinical uses of the CSS-BI The College Survey for Students with Brain Injury (CSS-BI [4]) was designed to identify health effects and academic challenges that those with TBI face. Kennedy et al. [5] had found evidence that those who reported more health-related issues endorsed more college challenges, although in that original study there was no comparison group. In the current study, responses from those without TBI were compared to an expanded sample of those with TBI to document psychometric properties of the college challenges sub-set of items. The internal reliability was strong and, for those with TBI, items clustered into four domains: studying and learning, time management and organization, social and nervousness or anxiety. Clinicians and researchers can be assured that the college challenges reflect the kinds of health effects experienced after TBI or during college for controls. Even though the structure of the latter two domains follows the authors’ original conceptualization for those with TBI, this is not the case for those without TBI. There are likely other challenges that typical college students have that were not included on the CSS-BI. Clinically, the CSS-BI can be used in structured interviews to gain a deeper understanding of how and why these challenges occur. Finally, items that were related to two factors provide evidence of the interconnections between college experiences after TBI. There were limitations to this study. First, there was limited demographic information available due to the online, largely anonymous approach. Anonymous surveys are typically used in the early stages of research when little is known, providing researchers with first-person perspectives. For example, Ness and Vroman [32] recently used anonymous self-reports of veteran college students with TBI and posttraumatic stress disorder (PTSD). The results from the current study confirm the range of health and academic challenges observed working with college students with mild, moderate and severe injuries, yet future studies should verify demographic information from medical records. Additional research is needed to document test–re-test stability of the CSS-BI and to provide theoretical explanations for four domains. Use of confirmatory factor analysis and external convergent validity measures in future studies will do this. Questionnaires such as The Behavior Rating Inventory of Executive Function–Adult version (BRIEF-A [33]), The MayoPortland Adaptability Inventory-4 (MPAI-4 [34]) and the Motivated Strategies for Learning Questionnaire (MSLQ [35]) will be useful, as well as neuropsychological tests and tests of language processing. To do this, larger sample sizes will be needed. Until then, the basic, preliminary psychometric evidence provided here gives clinicians and researchers some confidence that the CSS-BI does what it was meant to do; to describe the kinds of college challenges that those with TBI report and to identify how these challenges are inter-related.

DOI: 10.3109/02699052.2014.955883

Acknowledgements The authors wish to acknowledge Jocelyn Yu, MA, for her contributions to data coding and to the many individuals with TBI who shared their college challenges with us.

Declaration of interest The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

Notes 1. Note that the CSS-BI also includes questions about rehabilitation, on-campus services and life changes, but responses to these are not included in this analysis. 2. Planned comparisons of health issues and college challenges were performed between the demographic and non-demographic subgroups. There were no significant differences (p  0.05) or trends (p  0.10). Therefore, data were collapsed across sub-groups, for all further analyses.

References 1. Harris JR, DePompei R. Provision of services for students with traumatic brain injury: A survey of Ohio colleges. Journal of Head Trauma Rehabilitation 1997;12:67–77. 2. Todis B, Glang A. Redefining success: Results of a qualitative study of postsecondary transition outcomes for youth with traumatic brain injury. Journal of Head Trauma Rehabilitation 2008;23:252–263. 3. Kennedy MR, O’Brien KH, Krause MO. Bridging person-centered outcomes and therapeutic processes for college students with traumatic brain injury. Perspectives on Neurophysiology and Neurogenic Speech and Language Disorders 2012;22:143–151. 4. Kennedy MRT, Krause MO. The College Survey for Students with Brain Injury. 2009. Available online at: http://neurocognitivelab. com/college-survey-for-students-with-brain-injury-2, accessed 31 October 2013. 5. Kennedy MRT, Krause MO, Turkstra L. An electronic survey about college challenges after traumatic brain injury. NeuroRehabilitation 2008;23:511–520. 6. Levin H, Kraus M. The frontal lobes and traumatic brain injury. Journal of Neuropsychiatry and Clinical Neurosciences 1994;6: 443–454. 7. Kim J, Whyte J, Hart T, Vaccaro M, Polansk, M, Coslett H. Executive function as a predictor of inattentive behavior after traumatic brain injury. Journal of the International Neuropsychological Society 2005;11:434–445. 8. Kennedy MRT, Coelho C. Self-regulation after traumatic brain injury: A framework for intervention of memory and problem solving. Seminars in Speech and Language 2005;26:242–255. 9. Vakil E. The effect of moderate to severe traumatic brain injury (TBI) on different aspects of memory: A selective review. Journal of Clinical & Experimental Neuropsychology 2005;27:997–1021. 10. Serino A, Ciaramelli E, Di Santantonio A, Malagu S, Servadei F, Ladava E. Central executive system impairment in traumatic brain injury. Brain Injury 2006;20:23–32. 11. Lombardi A, Gerdes H, Murray C. Validating an assessment of individual actions, postsecondary supports, and social supports of college students supports, and social supports of college students with disabilities. Journal of Student Affairs Research and Practice 2011;48:107–126. 12. Dawson DR, Schwartz ML, Winocur G, Stuss D. Return to productivity following traumatic brain injury: Cognitive, psychological, physical, spiritual and environmental correlates. Disability & Rehabilitation 2007;29:301–313. 13. Dawson DR, Cantanzaro AM, Firestone J, Schwartz M, Stuss DT. Changes in coping style following traumatic brain injury and their relationship to productivity status. Brain and Cognition 2006;60: 214–216.

College survey for students with brain injury

1757

14. Mealings M, Douglas J, Olver J. Considering the student perspective in returning to school after TBI: A literature review. Brain Injury 2012;26:1165–1176. 15. Hux K, Bush E, Zickefoose S, Holmberg M, Henderson A, Simanek G. Exploring the study skills and accommodations used by college student survivors of traumatic brain injury. Brain Injury 2010;24:13–26. 16. Willmott C, Ponsford J, Downing M, Carty M. 2014. Frequency and quality of return to study following traumatic brain injury. The Journal of Head Trauma Rehabilitation 2014;29:248–256. 17. Tinsley HEA, Tinsley DJ. Use of factor analysis in counseling psychology research. Journal of Counseling Psychology 1987;34: 414–424. 18. Kennedy MRT, Krause MO. Self-regulated learning in a dynamic coaching model for supporting college students with traumatic brain injury: Two case reports. Journal of Head Trauma Rehabilitation 2011;26:212–223. 19. Taylor DJ, Bramoweth AD, Grieser EA, Tatum JI, Roane BM. Epidemiology of insomnia in college students: Relationship with mental health, quality of life, and substance use difficulties. Behavior Therapy 2013;44:339–348. 20. Cantor JB, Gordon W, Gumber S. What is post TBI fatigue? NeuroRehabilitation 2013;32:875–883. 21. Ouellet MC, Morin CM. Fatigue following traumatic brain injury: Frequency, characteristics, and associated factors. Rehabilitation Psychology 2006;51:140–149. 22. Bay E, Xie Y. Psychological and biological correlates of fatigue after mild-to-moderate traumatic brain injury. Western Journal of Nursing Research 2009;31:731–747. 23. Hiott DW, Labbate L. Anxiety disorders associated with traumatic brain injuries. NeuroRehabilitation 2002;17:345–355. 24. van der Horn HJ, Spikman JM, Jacobs B, van der Naalt J. Postconcussive complaints, anxiety, and depression related to vocational outcome in minor to severe traumatic brain injury. Archives of Physical Medicine and Rehabilitation 2013;94:867–874. 25. Hunt J, Eisenberg D. Mental health problems and help-seeking behavior among college students. Journal of Adolescent Health 2010;46:3–10. 26. Blanco C, Okuda M, Wright C, Hasin DS, Grant BF, Liu SM, Olfson M. Mental health of college students and their non-collegeattending peers: Results from the National Epidemiologic Study on Alcohol and Related Conditions. Archives of General Psychiatry 2008;65:1429–1437. 27. Eames P, Cotterill G, Kneale TA, Storrar AL, Yeomans P. Outcome of intensive rehabilitation after severe brain injury: A long-term follow-up study. Brain Injury 1996;10:631–650. 28. Olver JH, Ponsford JL, Curran CA. Outcome following traumatic brain injury: A comparison between 2 and 5 years after injury. Brain Injury 1996;10:841–848. 29. Turkstra LS. Should my shirt be tucked in or left out? The communication context of adolescence. Aphasiology 2000;14: 349–364. 30. Haycock LA, McCarthy P, Skay CL. Procrastination in college students: The role of self-efficacy and anxiety. Journal of Counseling and Development 1998;76:317–324. 31. Spitz G, Scho¨nberger M, Ponsford J. The relations among cognitive impairment, coping style, and emotional adjustment following traumatic brain injury. The Journal of Head Trauma Rehabilitation 2013;28:116–125. 32. Ness BM, Vroman K. Preliminary examination of the impact of traumatic brain injury and posttraumatic stress disorder on selfregulated learning and academic achievement among military service members enrolled in postsecondary education. The Journal of Head Trauma Rehabilitation 2014;29:33–43. 33. Roth RM, Isquith PK, Gioia GA. BRIEF-A: Behavior Rating Inventory of Executive Function - Adult Version. Lutz, FL: Psychological Assessment Resources; 2005. 34. Malec J. The Mayo-Portland Adaptability Inventory. The Center for Outcome Measurement in Brain Injury; 2005. Available online at: http://www.tbims.org/combi/mpai, accessed 22 October 2013. 35. Pintrich PR, Smith D, Garcia T, McKeachie W. A manual for the use of the Motivated Strategies for Learning Questionnaire (MSLQ). Ann Arbor, MI: The University of Michigan; 1991.

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