Exploring cognitive support use and preference by college students with TBI: A mixed-methods study

Abstract

PURPOSE:

Many college students with TBI rely on external strategies and supports to compensate for persistent memory, organization, and planning deficits that interfere with recalling and executing daily tasks. Practitioners know little, however, about the supports students with TBI choose for this purpose, the reasoning behind their choice, or preferred features of selected supports. The purpose of this study was to explore these issues.

METHOD:

We collected and analyzed quantitative and qualitative data from eight college students with TBI for completion of a concurrent triangulation mixed-methods design. Data analysis included evaluation and triangulation of participant demographic information, survey responses about persistent post-injury symptoms, transcripts from semi-structured interviews about cognitive support devices and strategies, and ranking results about specific compensatory tools.

RESULTS:

Results suggest that college students with TBI prefer high-tech external supports—sometimes with the addition of low-tech, paper supports—to assist them in managing daily tasks. This preference related to features of portability, accessibility, and automatic reminders. An electronic calendar was the most-preferred high-tech support, and a paper checklist was the most-preferred low-tech support.

CONCLUSIONS:

Rehabilitation professionals should consider implementing high-tech supports with preferred characteristics during treatment given the preferences of students with TBI and the consequent likelihood of their continued long-term use following reintegration to community settings.

Keywords

Traumatic brain injury student survivors cognitive deficits external supports

1 Introduction

Many individuals with traumatic brain injuries (TBIs) demonstrate cognitive deficits and difficulties with executive functioning that interfere with performing functional daily activities (Brown & Hux, 2016; Perna, Loughan & Talka, 2012). These residual cognitive and executive functioning impairments are associated with decreased memory, organization, planning, and error-monitoring skills that interfere with recalling and executing daily living tasks (Anderson, Jacobs, & Anderson, 2008; Arciniegas, Held & Wagner, 2002; Shanahan, McAllister, & Curtin, 2011).

Cognitive and executive functioning deficits are particularly concerning among individuals returning to postsecondary schooling following TBI (Hawley, Ward, Magnay & Mychalkiw, 2004; Martinez & Dovalos, 2016). Given improved medical and rehabilitative treatment as well as increased access to accommodations and compensatory aids, more and more individuals who have sustained TBIs pursue college or professional education following injury (Ackerman, DiRamio, & Mitchell, 2009; Kennedy, Krause, & Turkstra, 2008; Sohlberg, Griffiths, & Fickas, 2014). In fact, some researchers have found that as many as 85% of individuals injured in adolescence enroll in postsecondary education (Catroppa et al., 2009; Ewing-Cobbs et al., 2004). The presence of persistent deficits, however, makes academic achievement for these students more challenging than it is for students without neurological impairments (Todis, Glang, Bullis, Ettel, & Hood, 2011). In particular, college students with histories of mild brain injury report experiencing more chronic health symptoms and academic deficits than their uninjured peers (Brown, Hux, & Schmidt, 2015). For example, Hawley and colleagues (2004) interviewed parents and teachers of children and adolescents returning to the school environment following mild to severe brain injuries and documented that two-thirds had difficulty with school work and displayed attention or concentration deficits; over one-third had impairments in memory and learning new information.

Diminished executive function, memory, attention, impulse control, and information processing are frequent challenges for students with TBI. Such abilities are critical for new learning and academic success, and deficits in these areas cause daily living problems and decreased quality of life (Glang, Ettel, Tyler, & Todis, 2013). Cognitive deficits, in particular, are critical contributors to academic struggles (Vu, Babikian, & Asarnow, 2011). As a result, professionals have documented the need for accommodations to support students with TBI in school environments (Hux et al., 2010); however, only about 30% of these students receive accommodations within the academic setting itself (Hawley et al., 2004).

The lack of accommodations provided to students with TBI sometimes occurs despite an individual’s adequate deficit awareness and recognition of pre-/post-injury changes in executing school-related tasks (Kelley et al., 2014); however, other students with TBI lack deficit awareness and, hence, do not pursue available accommodations (Tate, Genders, Mathers, Rosenkoetter, & Motbey, 2011). Some students with TBI also report a desire to not use accommodations due to the stigma attached with such provisions (Kennedy, Krause, & Turkstra, 2008; Todis & Glang, 2008). Hence, although many higher education institutions have academic accommodation services available, students with TBI may fail to use them. In other cases, postsecondary campuses are simply unequipped to serve the unique and complex needs of students with TBI (Edwards & Parks, 2015). The result is that students with TBI may need to assume personal responsibility for implementing needed cognitive supports.

The severity of an individual’s persisting deficits and the consequent impact on daily living may vary across settings and contexts, thus resulting in a need to implement multiple compensation strategies or supports (Ylvisaker & Feeney, 1996). As such, many intervention efforts focus on (a) determining materials likely to be beneficial in various situations, (b) designing and personalizing support materials, and (c) promoting appropriate selection of supports and their implementation in specific settings.

Recent attention in clinical and research reports has centered on the adoption of external low- and high-tech cognitive supports (e.g., daily planners, electronic calendars, written lists) and the functional contexts in which these supports foster independence for individuals with neurological impairments (DePompei et al., 2008). For example, after performing a systematic review of cognitive rehabilitation research, Cicerone and his colleagues (2011) recommended direct attention, memory, and metacognitive strategy training coupled with the adoption of internal and external compensatory supports to reduce cognitive and functional disability at the post-acute stage of TBI recovery. According to researchers, the most efficacious and important clinical approaches include the combined use of support materials and external cues (DePompei et al., 2008; Dowds, Lee, & Sheer, 2011). In particular, assistive technology supports effective in minimizing the impact of cognitive challenges appear to benefit individuals with TBI regardless of age, severity, or time since injury (Leopold, Lourie, Petras, & Elias, 2015).

Adult students with TBI appear to benefit particularly from external supports for executive functioning deficits affecting planning, organizing, recalling, and completing tasks (Aldrich & Obrzut, 2012). Researchers have documented the positive impact of high-tech electronic supports (e.g., Gillette & DePompei, 2004; Hendricks et al., 2015); however, research is lacking about the types of supports consistently and independently implemented by adult students with TBI. Personal preference information regarding various support systems and features is critical for clinicians trying to select, design, and provide instruction about implementing supports for task planning, recall, and execution. The importance of implementing highly effective and preferred assistive devices for adults with TBI is critical given that 90% of assistive technology devices are rejected by individuals with cognitive deficits following a short usage period (Scherer, 2005).

The supports available to individuals with TBI include a multitude of high- and low-tech materials used routinely by people without acquired disabilities as well as supports designed specifically for those with cognitive impairments (Rumrill et al., 2016; Wallace & Bradshaw, 2011). The variety of materials available is quite diverse, including everything from written lists and notes to personal digital assistants (PDAs) and app software for phones and tablets. Extensive research has highlighted the effectiveness of high-tech support use by individuals with TBI and other cognitive deficits in general (Dowds et al., 2011; Gillettte & DePompei, 2004; Gillette & DePompei, 2008; Hart, Buchhofer & Vaccaro, 2004); however, researchers have yet to explore the aids independently selected and implemented by adult students with TBI.

Understanding how various features of external cognitive aids support the residual skills or exacerbate the challenges displayed by people with TBI remains largely unexplored. In addition, little research exists about factors contributing to the choices individuals with acquired cognitive deficits make regarding specific systems and their efforts to remain diligent in using them for an extended period of time in natural settings. Given this situation, we implemented research using a mixed-methods design to explore the experiences, feelings, and preferences of postsecondary student with TBI when selecting and implementing low-tech and high-tech external cognitive supports to help with performing daily activities and tasks required in college settings. The primary research questions addressed the cognitive support preferences of college students with TBI and the reasons for those preferences; hence, we used both quantitative and qualitative data sources for comparison and convergence of results.

The quantitative questions underlying this research were:

What deficits or symptoms do individuals with TBI report experiencing upon their return to postsecondary school environments that prompt the use of external cognitive supports?

What features of external cognitive supports do postsecondary students with TBI prefer?

Do adult students with TBI report an overall preference for low- or high-tech external cognitive supports?

The qualitative questions underlying this research were:

How do postsecondary students with TBI describe their experiences selecting external cognitive supports for completion of daily activities?

How do postsecondary students with TBI describe their experiences implementing external cognitive supports?

What are the feelings of postsecondary students with TBI regarding various low- and high-tech external supports?

2 Methods

We implemented a concurrent triangulation mixed-methods strategy for study completion (Martella, Nelson, Morgan, & Marchand-Martella, 2013). This approach allowed for collection of quantitative and qualitative data in tandem to promote information synthesis and achieve robust, in-depth explanations of the experiences and preferences of college students with TBI when using cognitive aids. Specifically, triangulation of both data types facilitated comparative analysis to determine whether data sources reached convergence and, thus, could be beneficial in building a clinical application model for selection and implementation of external cognitive aids by individuals in this population.

Quantitative data sources for triangulation included participant medical and educational history, scores on available cognitive standardized assessment measures, participant symptom self-reports, and rankings of presented external cognitive aids.

The primary qualitative data source was one-on-one semi-structured interviews with study participants. We used a transcendental phenomenological design approach documented by Moustakas (1994) to explore the shared experiences of postsecondary students with TBI when using external cognitive supports to compensate for executive function deficits (Creswell, 2013; Merriam, 2009). Phenomenological research allows for the search of meanings and perceptions among a group of individuals regarding a particular situation, concept, or phenomenon. The inherent phenomenological research process and analysis procedures then provide a method of investigating larger themes and meanings to derive those shared among participants versus those unique to a participant subset or individual person (Bogdan & Biklen, 2007; Creswell, 2013; Starks & Trinidad, 2007). We selected a phenomenological approach because of the importance of understanding the shared life experiences of postsecondary students with TBI and their overall preferences for types of cognitive supports. Past quantitative research studies have documented the extent to which external cognitive aids assist student survivors of TBI but have not addressed students’ experiences with independent use of these aids and preferences for specific characteristics. The inclusion of a qualitative portion to the design for the current investigation provided a means of acquiring rich descriptions of student experiences, preferences, and beliefs regarding assistive technology use that have been missing components in quantitative studies that do not include participants’ perspectives.

We received Institutional Review Board approval for the research prior to initiation of any data collection procedures.

2.1 Participants

2.1.1 Inclusion criteria

Researchers have established that neither initial injury severity nor the appearance of specific symptoms during acute recovery are good predictors of long-term, functional outcome (Grajzel, Klebe, & Gavett, 2015; McAllister & Arciniegas, 2002; McCrory et al., 2013). Also, researchers have documented a lack of correlation between self-report measures and formal tests of executive functioning for individuals with mild TBI (Donders, Oh, & Gable, 2015), and many adults with TBI perform relatively well on structured tests but persist in experiencing difficulties in real-world settings (Ylvisaker & Feeney, 2002; Shanahan, McAllister, & Curtin, 2011). Because of these phenomena, we decided not to rely on initial injury severity or standardized testing results as selection criteria. Instead, we included individuals as study participants if they had medically-documented TBIs and self-reported at least five persistent deficits on a TBI symptom checklist (see Appendix). Although adults with TBI often exhibit self-awareness and self-regulation challenges (Bach & David, 2006; Gordon et al., 2000; Kennedy & Coelho, 2005; Ownsworth, Quinn, Fleming, Kendall, & Shum, 2010; Sherer, Hart, & Nick, 2003; Sherer et al., 2003), the extent of recovery experienced by participants in the current study was sufficient to allow acceptance into a postsecondary institution, and, thus, self-awareness levels were likely adequate for self-reporting chronic deficits experienced post-injury and for participating in experimental interview and rating tasks. We considered the understanding of self-reported deficits experienced across functional tasks and environments as vital to building holistic participant profiles. Other eligibility criteria included: (a) speaking English as a primary language; (b) reliance on natural speech as a primary communication modality; (c) adequate hearing acuity for conversational speech as determined through informal conversation with a member of the research team (i.e., a trained speech-language pathologist); (d) current or pending (i.e., within six months) enrollment in at least one postsecondary class; and (e) no history of neurological problems or learning disabilities other than those associated with TBI.

Eighteen potential participants from two Midwestern Universities contacted us about study participation; however, only eight met the inclusion criteria. According to experts in qualitative and mixed methods research (e.g., Creswell, 2013), inclusion of eight participants for evaluation by descriptive and qualitative means is sufficient for phenomenological study analysis. Demographic and injury information about each participant appears in Table 1.

Table 1
Participant Demographic and Injury Information

Participant Gender Age Injury Injury Time post Living

number severity etiology most recent status

injury (months)

1 F 28 Mild Fall 80 Independent

2 M 20 Severe MVA 14 Independent

3 M 39 Severe MVA 66 Independent

4 F 22 Severe MVA 28 Transitional

rehabilitation

5 M 35 Severe MVA 210 Transitional

rehabilitation

6 F 19 Mild Falls 6 Independent

7 F 19 Mild MVA 11 Independent

8 M 23 Mild Fall 96 Independent

Participant	Gender	Age	Injury	Injury	Time post	Living
1	F	28	Mild	Fall	80	Independent
2	M	20	Severe	MVA	14	Independent
3	M	39	Severe	MVA	66	Independent
4	F	22	Severe	MVA	28	Transitional
						rehabilitation
5	M	35	Severe	MVA	210	Transitional
						rehabilitation
6	F	19	Mild	Falls	6	Independent
7	F	19	Mild	MVA	11	Independent
8	M	23	Mild	Fall	96	Independent

Note. MVA = motor vehicle accident.

Four study participants (i.e., Participants 2, 3, 4, and 5) had experienced severe TBIs—that is, injuries resulting in at least 24 hours of lost consciousness and more than one week of post-traumatic amnesia (Fortuny, Briggs, Newcombe, Ratcliff, & Thomas, 1980). We confirmed initial injury severity through participant report and medical documentation when available. All participants with histories of severe TBI had received acute, post-acute, and transitional living rehabilitation during the course of initial injury recovery.

An additional four participants (i.e., Participants 1, 6, 7, and 8) reported having experienced mild injuries—labeled as concussions for study purposes. Participants 1, 7, and 8 sustained single concussions for which they lost consciousness for less than five minutes, received medical treatment, and reported enduring persistent cognitive complaints. Participant 6 reported three concussive injuries across her lifespan. She lost consciousness for approximately ten minutes at the time of the most recent event; no loss of consciousness occurred as a result of the prior events. Although all participants with mild TBI received medical attention following injury, only two of the four (i.e., Participants 1 and 6) received specialized rehabilitation services for cognitive deficits from an outpatient clinic.

Of the participants currently enrolled in college-level courses (Participants 1, 2, 3, 6, 7, and 8), only Participants 7 and 8 did not receive academic accommodations (e.g., extended time on tests, assignment extensions, peer note-takers) to support persistent cognitive deficits relating to TBI. Participants 4 and 5 were scheduled to begin postsecondary courses within the next six months but had not yet explored the possibility of receiving academic accommodations.

2.1.2 Cognitive profile

Selection of standardized test results performed prior to research initiation was variable across participants given their diverse injury severities and lengths of time post-injury. Three of the participants with concussion histories (i.e., Participants 6, 7, and 8) performed within normal limits on the attention, memory, executive functioning, language, and visuospatial skill domains of the Cognitive Linguistic Quick Test (CLQT; Helm-Estabrooks, 2001), thus establishing they had adequate cognitive functioning in basic skills. Participant 3 also performed the CLQT and achieved scores within normal limits for memory, language, and visuospatial skills with mild deficits noted in attention and executive functions. Participants 2 and 4 demonstrated severe verbal learning and verbal memory deficits, moderate verbal fluency challenges, and mild visuospatial and naming deficits characterized by performance on assessments such as the Hopkins Verbal Learning Test-Revised (Brandt & Benedict, 2001), FAS test (Spreen & Benton, 1977), Behavior Rating Inventory of Executive Function (Gioia, Isquith, Guy, & Kenworthy, 2000), and Trail Making Test (Reitan & Wolfson, 1985). Participant 5 demonstrated basic expressive and receptive language skills within normal limits as determined by the Western Aphasia Battery-Revised (Kertesz, 2006) and demonstrated executive function and visuospatial skills within normal limits according to the CLQT. Standardized test results were not available for Participant 1.

2.2 Data collection

Data collection consisted of four steps: (1) collecting background information, (2) completing TBI symptom checklists (see Appendix), (3) engaging in semi-structured interviews, and (4) rating external support preferences. We collected data for each participant independently. Figure 1 depicts both quantitative and qualitative data collection andanalysis procedures.

Fig.1

Mixed-methods data collection and analysis procedures.

Participants completed a pre-interview background form to provide demographic information such as the date and type of injury, current living arrangements, and educational status. These data served a primary purpose of establishing study eligibility and ascertaining pertinent medical and educational history. Demographic information was used in data triangulation as appropriate. Participants then completed a 54-item checklist of persistent symptoms experienced following injury acquisition (see Appendix). We adapted this checklist from a more extensive one found on the Head Injury Hotline website (1998) to obtain information about specific symptoms experienced by students with TBI when functioning in educational settings. The original checklist included 103 potential symptoms across six categories. To reduce redundancy and participant burden, we adapted the list to emphasize symptomology reported in extant literature and consistently endorsed by individuals with persistent challenges following TBI (Gordon et al., 1998; Gordon, Haddad, Brown, Hibbard, & Sliwinski, 2000; Kennedy et al., 2008; Krause & Richards, 2014; McAllister & Arciniegas, 2002). This adapted checklist included five categories of persistent symptomatology: (a) intellectual impairments, (b) psychological consequences, (c) physiological impairments, (d) personality alterations, and (e) neurological problems.

Following collection of background information, we engaged a participant in a semi-structured interview to explore current and past experiences with external support tools and strategies as well as preferences regarding external support material characteristics. Queries first addressed an individual’s current use of external cognitive support systems by asking general, open-ended questions (e.g., “Tell me about how you organize your daily tasks,” “Tell me about your experiences using materials to help you organize your day,” and “Why did you choose a particular aid?”). We then asked follow-up questions with increased structure and guidance for facilitating participant responses about the characteristics and usefulness of his/her current systems for planning, organizing, recalling, and executing tasks. Subsequent questions explored a participant’s feelings regarding low-tech (i.e., paper and pencil) and high-tech (i.e., electronic) support materials. We asked a participant for his/her overall preference of paper and pencil systems, electronic systems, or a combination of both. Follow-up questions focused on characteristics a participant liked or disliked about low- and high-tech supports. Additionally, we provided each participant with eight example materials and asked about likes and dislikes for each. The four low-tech supports included a monthly paper calendar, a paper checklist, sticky notes, and a daily planner book; the four high-tech supports included electronic lists, voice memos, a digital calendar with pop-up reminders, and an application for scheduling. As a final task, each participant reviewed all eight example materials, selected the two most preferred, and explained the rationale for his/her selections.

Data collection occurred during one session and lasted approximately 30 to 60 minutes per participant. A member of our research team conducted the interviews and facilitated capture of ranking procedures while capturing a digital audio-recording of responses and recording field notes. Subsequently, a trained member of the research team transcribed verbal responses from each of the eight interviews, and a second team member reviewed all transcripts for accuracy prior to the initiation of data analysis procedures.

2.3 Data analysis

2.3.1 Quantitative data

Primary data included self-reported symptoms experienced since injury and rankings of presented low- and high-tech systems; participant demographic information, brain injury history, and results of standardized testing were used in data triangulation as appropriate. We calculated the average number of self-reported symptoms across participants within each symptom category and evaluated responses to determine the most highly endorsed symptoms. We also summed ranking data to determine participants’ most frequently selected first and second choices within low- and high-tech categories and across system options.

2.3.2 Qualitative data

We analyzed collected qualitative data primarily using Moustakas’ transcendental approach to phenomenology with triangulation of transcriptions and field notes (Moustakas, 1994; Creswell, 2013). With this transcendental approach, we progressed from narrow units of analysis to the creation of broader themes. We first compared each of the answers provided in the semi-structured interview through horizontalization and highlighted specific statements that revealed information about the individual’s experiences and opinions. Horizontalization required consideration of all conversational turns and analysis of each piece of data with equal weight, thus leading to the development of narrow meaning units. These narrow units served as the basis for creating broad themes, or clusters of meaning, which were present across participants. Finally, we analyzed the identified themes to determine an overall essence of the shared experiences of this subgroup of individuals with TBI (Creswell, 2013; Moustakas, 1994).

All members of the research team jointly analyzed one transcript to ensure the reliability of data analysis procedures. Two of us separately analyzed all subsequent transcripts and data forms and developed initial themes and subthemes present within the data. After categorizing and developing themes independently, we jointly identified emerging themes and reached consensus about each theme label and defining characteristics or subthemes. Additionally, we focused on epoche—also known as bracketing or suspending judgment—during the data collection and analysis process to decrease the influence of professional bias on data interpretation. Epoche was necessary to ensure that prior beliefs did not interfere with exploration of the phenomena being studied given our backgrounds as speech-language pathologists and our clinical experiences working with college students with TBI (Creswell, 2013; Merriam, 2009).

We used two types of verification procedures to establish validity of the qualitative results: (a) member checking and (b) searching for disconfirming evidence. Member checking involved online verification of information in instances in which the interviewer needed clarification. This was achieved through the generation of summary statements, yes/no questions, and follow-up questions, as needed, during the interview process. As suggested by Harper and Cole (2012), member checking during an interview through restating or summarizing information and questioning a participant to determine accuracy increases study credibility (Creswell, 2007; Lincoln & Guba, 1985). Finally, we searched for disconfirming evidence of information reported among the participants. Identified themes and subthemes were consistent across the eight participants; however, some individual differences in preference and rationale emerged. These individual preferences were not surprising given differences in the nature of participants’ persistent deficits and are reflective of the relative heterogeneity present among adults with TBI.

2.3.3 Data triangulation

Triangulation involved integration of information obtained from quantitative and qualitative sources. We gave equal weight to quantitative and qualitative data during triangulation. Using the traditional convergence model of triangulation (Doyle, Brady, & Byrne, 2009), we evaluated and compared data during the interpretation phase to determine whether convergence was reached across data types and participants. This triangulation and convergence process facilitated the development of clinical application guidelines for cognitive support system selection and implementation by college students with TBI (see discussion).

3 Results

3.1 Persistent symptom checklist

Participants reported experiencing between five and 38 persistent symptoms following injury (M = 12.75, SD = 10.43, Median = 10) out of a total 54 listed possibilities. As shown in Table 2, one outlier was evident in the reporting of symptomatology in that seven participants endorsed between five and twelve persistent complaints, whereas one participant (i.e., Participant 6) endorsed 38. All participants reported persistent intellectual impairments and psychological consequences. Intellectual impairments most commonly included attention difficulties (n = 4), problems with concentration (n = 5), distractibility (n = 5), and memory challenges (n = 5). The most commonly reported psychological consequences were feelings of discouragement (n = 5) and that others did not appreciate their difficulties (n = 4). Additionally, seven of the eight participants reported persistent physiological impairments (e.g., headaches and feelings of restlessness); however, only five participants reported persistent personality alterations (e.g., chronic frustration and impulsivity), and only four reported neurological problems (e.g., seizures and blurred vision).

Table 2
Number of Persistent Impairments Endorsed by Participants in each of Five Symptomatology Categories

Participant Intellectual Psychological Physiological Personality Neurological TOTAL

impairments consequences impairments alterations problems

(n = 28) (n = 9) (n = 5) (n = 9) (n = 3)

1 5 3 0 0 0 8

2 5 6 1 3 0 11

3 2 2 1 0 0 5

4 7 1 2 0 2 10

5 6 2 2 1 1 12

6 21 5 5 5 2 38

7 5 1 2 1 1 10

8 5 1 1 1 0 8

TOTAL 56 21 14 11 6

Participant	Intellectual	Psychological	Physiological	Personality	Neurological	TOTAL
1	5	3	0	0	0	8
2	5	6	1	3	0	11
3	2	2	1	0	0	5
4	7	1	2	0	2	10
5	6	2	2	1	1	12
6	21	5	5	5	2	38
7	5	1	2	1	1	10
8	5	1	1	1	0	8
TOTAL	56	21	14	11	6

3.2 Current support system selection and use

Three participants (i.e., P1, P2, and P6) reported currently using low-technology external aids as their primary source of support for completing daily living, educational, vocational, and social activities, and four (i.e., P3, P4, P5, and P8) reported using high-technology supports. Participant 7 indicated that she did not have a current system to support memory, stating that she instead retained information “in her head.” Regarding system selection, three participants (i.e., P1, P6, and P7) claimed to have selected systems independently, and the remaining four selected and implemented supports based on clinician suggestion or direct clinician support.

3.3 Preferred support material characteristics

Analysis of transcripts revealed four subthemes regarding preferred external cognitive support system components (see Fig. 2). These preferences did not relate to specific support systems; instead, they reflected generalizations about preferred external support system characteristics or components. The subthemes included: (a) having access to pop-up reminders; (b) system portability, convenience, and access; (c) task prioritization features; and (d) having adequate space for recording notes.

Fig.2

Preferred support material characteristics and participant explanations.

Participants stated that having pop-up reminders within a system was a desired feature on electronic devices (P1: I like the fact that work really awesome in terms of reminding me for things.; P4: You can put alerts in your phone.; P4: I can just put it [event] in my phone, and it’ll [phone] just like alert me.). This need to rely on external reminders to complete tasks or arrive at specific locations or events on time is consistent with the difficulties participants reported with memory and attention (P2: It reminds me even when I don’t remember to do things.; P3: A little buzz happens, and I look and am like, oh yeah, don’t forget to go to that.). Participants expressed that their greatest need for reminders was for prospective and/or novel tasks (P2: If it’s something that usually doesn’t happen, it will remind me to do it.; P1: Especially if it’s a reminder for something later on.). They further specified a preference for reminders that could be set at various lengths of time prior to an event (P2: I have it [phone] remind me an hour before and a half hour before.; P1: A lot of times, I will have a reminder go off the day before.; P8: I get pop-ups every few minutes. … And I always check my phone every 15 [or] 10ish minutes.).

Portability, convenience, and easy access also emerged as preferred support material characteristics for students with TBI. Participants reported a preference for materials that were small in size (P2: I like that it [phone] is small.), easy to carry (P3: I like that it [phone] is … easy to carry.; P4: My phone is small, and it’s easy to carry; P5: I can carry it [iPad] with me everywhere I go.; P4: There is no way you could bring this [monthly paper calendar] with you every day.), and currently present in their daily lives (P3: I already have it with me.; P4: I just like it because it’s [phone] always with me.; P3: It [information] is in one place all the time. I already know where it is.; P6: My phone is with me all the time.). They also preferred support materials that automatically synced information across electronic devices (e.g., phone, computer, and tablets) and, hence, allowed access from a variety of locations (P3: If it goes on there [phone], it’s going on my computer.; P4: Whatever I put in my phone, it automatically goes to my iPad.; P5: What’s in my phone goes on my computer.; P7: I noticed that it [electronic calendar] syncs to my phone which is cool too.).

Prioritizing capabilities emerged as another preferred characteristic of support systems for college students with TBI. All participants commented about having difficulty prioritizing tasks during the day. As a result, high-tech systems containing features that allowed for ordering information based on importance or low-tech systems that provided a space to designate task priority were preferred (P5: I like it [to-do lists] because of the order.; P2: You can prioritize and strategize, like, this is more important, or this will take less time, so I can get that out of the way.; P2: You can see what’s more important than the other things.; P4: It’s laid out, so I know to do this, this, this, this, and this.; P6: I can break it up into steps, and it makes it seem like I can accomplish it all.).

Adequate space for notes emerged as the final support material characteristic preferred by study participants (P1: The reason I liked it is because I have notes at the bottom.; P1: I also like the fact that it gives me room to write.). Specifically, writing down important information served as a memory support, and, thus, participants regarded this feature as an important contributor to their successful completion of tasks (P1: If I can’t write it down, then [it’s] probably not going to happen.; P2: Writing things down is massive … very helpful for me.; P6: I feel like I’m more likely to remember things once I start writing.).

3.4 Support system preferences

We asked participants which support system type (i.e., electronic, paper-based, or a combination of both) they would generally prefer to use in their daily lives. Three of the eight participants (i.e., P2, P4, and P5) stated a preference for electronic supports, with another three (i.e., P6, P7, and P8) reporting a preference for paper-based systems. The remaining two preferred a combination of electronic and paper-based supports. Overall, these preferences did not relate to a participant’s current age or age at time of injury. For example, participants 6, 7, and 8—who were among the youngest participants in the study—selected paper-based systems as their most preferred supports. In contrast, participant 5—the second oldest participant and the one who was the longest time post-injury—most preferred electronic supports. As depicted in Fig. 3, subthemes emerged about likes and dislikes associated both with low-tech and high-tech systems.

Fig.3

High- and low-tech system likes and dislikes.

3.4.1 Low-tech system and dislikes

Participants generally commented about three positive features associated with low-tech external support systems. First, they liked the fact that low-tech systems provided a tangible reference of having completed a task. Marking a task as complete provided a sense of satisfaction and served as evidence of progress (P1: I like checking things off.; P2: I like crossing things off a lot. … It makes me feel awesome.; P4: I like that you can highlight it when you’re done.; P6: It’s really satisfying when you can check things off.). Second, participants liked the easy accessibility and affordability of low-tech systems (P2: Paper/pencil is just easier to find. … I can just grab a pen and write on it [paper].; P5: Cheap [post-its].). Specifically, they reported liking low-tech systems that they could create themselves by using materials already available in their homes (e.g., paper calendar, paper to-do lists) and, hence, not requiring the purchase of additional materials. Finally, participants reported a preference for the lack of organizational constraints present in low-tech systems (P2: Organization would be a pretty big deal.; P5: You can add and remove things easily.; P8: I can express myself easily with writing.). Analysis of the transcripts revealed that each participant demonstrated a unique way of organizing daily tasks regardless of the support system implemented. Thus, being able to alter a system to match individual preferences emerged as a key factor (P1: I don’t like being limited.; P8: I wish there was some sort of transition between pencil/paper and putting it [tasks] entirely online.).

Participants also disliked certain characteristics of low-tech systems. In particular, they found that paper-based external supports were easy to misplace, and they disliked having to carry an additional item with them solely for the purpose of supporting daily task performance (P1: [Planner] is an extra thing to do.; P4: Just another accessory.; P4: It would be like clutter.; P4: Hard to carry.; P2: Having to carry it around everywhere would kind of be bothersome.; P8: Yeah, even if I could write things down, I couldn’t carry it [paper-based system].).

3.4.2 High-tech system likes and dislikes

Data analysis revealed three characteristics—all of which addressed system flexibility or personalization—that contributed to the desirability of high-tech supports. One such feature was limitless space capacity. Study participants reported preferring support materials that allowed for storage of large amounts of information in one system or device (P2: You can put a ton of information on there.; P2: You can just keep adding to it [an electronic list] if you need to.). Participants also appreciated that high-tech support systems allowed them to edit information as needed without creating visual clutter (P4: I can make a change, lickety-split.; P6: They [electronic systems] are really easy to edit and use.). Finally, participants again referenced the importance of having a system capable of providing reminders for task completion (P2: A piece of paper doesn’t beep at you and say, ‘hey, you need to do this.’; P1: [I use it] just to jog my memory.; P3: My phone reminds me like three hours before.; P4: [I like an electronic list] instead of having a planner, which will not alert me when I have something to do.; P8: It [electronic system] is much more efficient ‘cause of the pop-ups.).

Participants reported only two characteristics they disliked about high-tech external cognitive support systems: the difficulty of mastering the associated technology and the expense of maintaining high-tech systems (P2: Technology is expensive.; P3: That [computers] cost a lot of money.; P7: I mean I don’t really know how any of the apps are set up.) Participants elaborated further by explaining that limitations in their knowledge about running electronic devices sometimes caused problems (P2: I’m very stuck in 1998 on my technology skills.; P5: It [technology] can get complicated.; P2: I don’t know how to do it [electronics] very well.; P4: Technology is complicated.; P7: It [digital calendar] looks kind of difficult.).

3.5 Overall preference ratings

Five of eight participants chose a high-tech support as their most preferred item when presented with the four low-tech (i.e., monthly paper calendar, paper checklist, sticky notes, and daily planner book) and four high-tech example systems (i.e., electronic lists, voice memos, digital calendar with pop-up reminders, and application for scheduling; P7: It [scheduling application] could replace my checklist in a more organized fashion.; P5: I prefer electronic, ‘cause I’ve never been one who enjoyed writing things.; P5: I know where to find it [electronic information]. It’s easy to store. It’s very effective and time efficient.; P1: For mass quantities of information, I’d probably use electronics; P8: It [digital calendar] appears on my phone, which I always carry. I never forget my phone.). Individual participant preference choices appear in Table 3. The most preferred high-tech item was a digital calendar with pop-up reminders (n = 3). However, six of the eight participants chose a low-tech support as their second-most preferred item (P2: I can just grab a pen and write on it.; P1: I like writing out my to-do lists.; P2: Paper/pencil is easier.; P1: For organizing my life, it’s probably just going to be paper.), with paper checklists of daily tasks (n = 2) and paper-based planner systems (n = 2) as the most common choices.

Table 3
Participant Support Material Preferences

Participant 1st choice 2nd choice

1 Paper-based planner Paper lists

2 Digital calendar Electronic lists

3 Paper calendar Sticky notes

4 Digital calendar Paper calendar

5 Voice memos Paper lists

6 Paper lists Digital calendar

7 Scheduling application Paper-based planner

8 Digital calendar Paper-based planner

Participant	1st choice	2nd choice
1	Paper-based planner	Paper lists
2	Digital calendar	Electronic lists
3	Paper calendar	Sticky notes
4	Digital calendar	Paper calendar
5	Voice memos	Paper lists
6	Paper lists	Digital calendar
7	Scheduling application	Paper-based planner
8	Digital calendar	Paper-based planner

4 Discussion

External cognitive aids serve to support executive functioning and assist with management of daily activities. Given the widespread cognitive deficits involving memory, planning, attention, and task execution experienced by individuals with TBI, many may benefit from external aids to enhance daily functioning (de Joode, van Heugten, Verhey, & van Boxtel, 2010; Patel, Coshall, Rudd, & Wolfe, 2003). Although several researchers have reported the positive impact of various external support systems for enhancing cognitive functioning among individuals with TBI, incomplete information is available regarding the most efficacious support methods (de Joode et al., 2010; Dowds, Lee, & Sheer, 2011; Gillette & DePompei, 2004, 2008; Hart et al., 2004). In particular, researchers have not previously explored the support system types and components preferred by individuals with TBI who are returning to postsecondary school settings. This lack of evidence to support therapeutic interventions and understand fully the needs of the students with TBI motivated the current study.

Extensive evidence exists relating to the need for correctly matching assistive technology (AT) devices to the individuals using them. For example, the Matching Person and Technology Model and Assessment Process provides rehabilitative professionals with a guide for identifying and addressing potential barriers to the use of external aids (Scherer & Craddock, 2002). Implementing such a process is essential to determining the best fit between AT devices/strategies and an individual user, because it directs attention to personal strengths and weaknesses, potential aversions to technology or certain aspects of technology, and the likelihood of a person implementing the support in relevant environments (Cushman & Scherer, 1995; Scherer, 2002, 2004, 2005; Scherer, Coombs, & Hansen, 2003). The foremost reason for abandoning assistive devices is the failure to consider the desires of the user (Scherer, 1993). Hence, regardless of the high- or low-tech nature of an external cognitive aid, the vital component is matching a system’s availability, complexity, and features to the personal needs of the user.

4.1 Developing a clinical model for system selection and implementation

Convergence and comparison of study findings resulted in the development of a clinical model for external supports system selection and implementation for college students with histories of TBI. As such, the study findings have important implications for the creation and adoption of clinical and rehabilitative strategies.

A recent review by an international group of researchers and clinicians (Togher et al., 2014) delineated important considerations for the rehabilitation of individuals with cognitive-communication disorders following TBI. Specifically, the panel recommended that therapeutic practices: (a) consider premorbid status; (b) be individualized to a person’s needs, goals, and skills; (c) include training in assistive technology use, when appropriate; and (d) occur in contexts that minimize the need for separate generalization efforts. Combining these recommendations with the data reported herein suggests that an iterative model of external support system selection and implementation—such as the one depicted in Fig. 4—may be beneficial for individuals with TBIs returning to postsecondary school settings. This three-phase model highlights the importance of implementing suggestions from an individual with TBI while working collaboratively with a trained rehabilitation professional.

Phase 1 of the clinical model focuses on collection of in-depth information about a person’s premorbid educational, vocational, and developmental status as well as educational accommodation and external cognitive support system use. It includes specific exploration of the person’s prior experiences learning and using external support systems in relation to persistent intellectual, psychological, physiological, personality, and neurological challenges as reported through completion of the TBI symptom checklist (Appendix). Given that postsecondary settings differ widely in their expectations regarding student responsibilities, accommodation implementation, and classroom structure, collaborative efforts among rehabilitation professionals, school-based disability specialists, and an individual student with TBI is most likely to facilitate development of an effective plan for addressing cognitive support needs as they relate to educational goals.

Fig.4

Clinical model for system selection and implementation.

Phase 2 addresses the identification and development of external support systems that are viable possibilities for supporting student needs. A first step involves introduction of a variety of low- and high-tech support system options for discussion of preferences and identification of potential barriers as addressed in this study. The emphasis should be on collaborative work to build a multimodal system targeting the unique needs and preferences of the student with TBI.

Phase 3 of the model focuses on providing instruction to the student, monitoring opportunities to use the support system in real-world contexts, and making adjusting and modifications to the system as necessary. Although not explored in the current study, such a procedure is important to facilitating effective long-term use. As such, regular meetings to engage in problem-solving discussions about system use successes and challenges are key to the iterative evaluation and implementation process. Even after initial successful development of an external support system, the need for modifications and additions may arise as the person with TBI expands his/her reintegration into multiple aspects of academic, vocational, and social communities.

4.2 Preference and motivation

Overall results of this concurrent triangulation mixed-methods study suggest that college student survivors of TBI experiencing persistent deficits as a result of injury prefer high-tech external supports—sometimes with the addition of low-tech paper and pencil supports—to assist them in managing daily tasks. This preference relates to features including portability, accessibility, and inclusion of automatic reminders. A digital calendar was the most-preferred high-tech item, and paper checklists were the most preferred low-tech item. As a group, participants reported the need for external support systems when presented with prospective events and tasks requiring implementation of executive functioning skills because of deviations from a normal routine. External supports with features addressing executive functioning challenges appear to be important for successful academic reintegration by this population. However, much debate persists about the effectiveness and continued use of high-and low-tech cognitive supports by individuals with cognitive deficits (de Joode et al., 2010).

College students with TBIs—as well as their peers without disabilities—rely on personal preferences and knowledge about their cognitive strengths and challenges to select methods of recording, organizing, and tracking information about completed and prospective activities. Because vast differences may exist across people, external support systems offering flexible features are more likely to satisfy the desires of multiple individuals than those with more rigid frameworks. Despite this, some of the commonalities experienced by students reintegrating into postsecondary settings following TBI create a scenario in which certain support system features have particular importance. Overall, participants in the current study expressed several preferences for external support system components and capabilities that align with high-tech systems (e.g., inclusion of pop-up reminders, accessibility from a variety of locations, ease of editing). However, they also reported potential disadvantages of such systems that may influence their likelihood of implementing an accommodation device on a consistent and long-term basis. Given Scherer’s (2005) finding that individuals with cognitive deficits abandon up to 90% of assistive technology devices after a short period of usage, acknowledging the salience of reported advantages and disadvantages is crucial. Additionally, the fact that previous research evaluating the implementation of cognitive aids by adults with TBI revealed no difference between electronic or paper-and-pencil aids (de Joode, van Huegten, Verhey, & van Boxtel, 2013), examining a client’s preferences becomes a critical component to the selection process. Attempts to impose organizational systems not matching an individual’s preferences or not meeting specified needs or desires will likely lead to system abandonment (Beigel, 2000).

Requesting that study participants reflect about and select preferences among eight external support systems with varying characteristics and potential uses revealed a general preference for electronic systems, often with a low-tech support system as a second choice. The variety of available supports and the unique preferences expressed by students with TBI confirms the importance of clinicians refraining from imposing their personal biases during the system selection and implementation process. Indeed, remaining flexible and acknowledging a client’s motivation to implement certain cognitive supports appears critical given that personal buy-in may substantially affect long-term implementation and successful use of such systems.

4.3 Generalizability of findings

Several factors limit the generalizability of the findings presented herein given that this mixed-methods study reported the experiences and preferences of only eight postsecondary students with TBI. In particular, the demographic characteristics of study participants varied greatly, particularly with regard to age, time post-injury, and severity of initial injury. Variability in age is an important consideration, because, in general, young adults may tend to report greater comfort using devices reliant on recent technological advances than their older counterparts. Although age did not relate directly to preferences for high- versus low-tech external supports in the current study, the possibility exists that a group of postsecondary students with TBI who are less variable in age and are closer in average age to traditional college students may have different preferences.

Similarly, variability in time post-injury may be an important consideration, because individuals who are several years post-injury may have had more intervention services, more experience using external cognitive supports, and/or more awareness of how their persistent cognitive challenges affect their daily lives than people with more recent injuries. Given that the current study participants included individuals with substantial variability regarding time post-injury, perceptions about the relative benefits and adverse effects of supports may have been skewed differentially based on unique post-injury experiences. Hence, although the themes were consistent across current study participants, the preferred support characteristics may not generalize to all student survivors of TBI.

Another factor limiting generalization of the study findings is that we elicited responses from participants based on initial reactions to potential supports and did not provide opportunities for hands-on trials with the support systems. Device trials are an important component of the assistive technology matching process. Further research involving in-depth analysis both of participant’s initial preferences and reactions to various external cognitive support systems and their responses following short-term device and strategy trials would be beneficial.

4.4 Conclusions

Rehabilitation professionals working with individuals with TBI have many issues to consider when suggesting the implementation of external cognitive supports. Early attention to support availability, complexity, flexibility, and cost during the rehabilitative process may enhance the likelihood of long-term use following reintegration to academic, vocational, and community settings. Instruction in the use of external compensatory aids and strategies with direct application to functional activities is a recommended practice guideline for those working with individuals with TBI (Cicerone et al., 2005). Based on the current study findings in addition to the evidence-based practice guidelines, adoption of a clinical model such as that suggested herein may help guide exploration, modification, and implementation of support devices specifically for the population of postsecondary students with TBI.

Conflict of interest

The authors report no declarations of interest.

Footnotes

Appendix

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