Artigo 1 Traumatic Brain Injury on Memory Qualitative Study

7/31/2019 Artigo 1 Traumatic Brain Injury on Memory Qualitative Study

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BRAIN INJURY, VOL. 18, NO. 5 (MAY 2004), 471495

Interview study of the effects of paediatric

traumatic brain injury on memory

H E A T H E R W A R Dy, D A V I D S H U My,

B O B D I C Kz, L Y N N E M C K I N L A Y } a n d

S I M O N E B A K E R - T W E N E Y }

y School of Applied Psychology and Neuropsychology Clinic, Griffith University,Brisbane, Australiaz Southern Cross University, Lismore, Australia

} Queensland Paediatric Rehabilitation Service, Royal Childrens Hospital, Brisbane,Australia

(Received 30 January 2003; accepted 31 October 2003)

Primary objective: To investigate the effects of traumatic brain injury (TBI) on childrens day-to-daymemory functioning.Research design: A qualitative, interview-based procedure.Methods and procedures: Thirteen parents of children and adolescents with TBI were interviewedfor 2 hours. Data from 12 of the interviews were analysed using content analysis, which involvedtranscribing notes, sorting information into categories, identifying similarities or differences among thecategories and isolating meaningful trends.

Main outcomes and results: Over half of the children experienced explicit (past recall) and prospectivememory (future intentions) loss, but few experienced implicit memory (e.g. procedural) loss. Further,parents utilized their own interventions in minimizing their childrens memory disabilities.Conclusion: Memory loss is common and can impact on everyday living, but is selective in the types ofmemory affected. Follow-ups are recommended to assess quantitatively, the so-far, little-known effectsof paediatric TBI on prospective memory and to examine more closely parent interventions to assesstheir wider applicability in TBI rehabilitation.

Introduction

Paediatric traumatic brain injury (TBI) is a major public health concern. It is aleading cause of death among the young and results in considerable neuro-behavioural morbidity [1]. For instance, 4050% of childhood deaths resultingfrom trauma are associated with brain injuries [2]. And, according to Michaud et al.([3], p. 345), the incidence of significant disability is 20% among survivors (andthat) traumatic brain injury is the most common cause of acquired disability inpaediatrics. Further, the TBI-induced disability faced by children and adolescentscan occur over a wide number of domains: physical, neurocognitive, behavioural,emotional and social [4, 5].


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This study focused on the effects of paediatric TBI on the neurocognitivedomain, in particular memory functioning. Memory is an area of neurocognitionthat is important to study for at least two reasons. First, memory deficits occurwith high frequency after TBI. For example, Levin and Eisenberg [6] noted after

conducting an analysis of composite scores obtained from children with TBI onmeasures of memory, language, motor and somatosensory functioning and visuo-spatial ability that memory was the most frequently disrupted domain. Secondly,memory impairments are likely to be a major obstacle for young TBI sufferers inboth everyday functioning and school performance [7]. For example, with memoryimpairments, children may be unable to remember names, keep track of eventsand narratives, follow the rules of games, keep appointments or remember to dohomework.

To date, most research on the effects of paediatric TBI on memory has assessedexplicit memory (e.g. Hannay and Levin [8], Jaffe et al. [9] and Yeates et al. [10]),

the retrospective memory sub-type requiring conscious awareness of past learningexperiences [1113]. Explicit memory is assessed by tests of free recall, cued recallor recognition and, at testing, the individuals attention is drawn to the priorlearning events [7, 12]. Explicit memory mediates functions such as rememberingnames, what occurred 10 minutes ago and items from a list. Results have consis-tently shown that children with TBI, compared to those without neurologicalimpairment, experience explicit memory deficits [810, 14, 15]. Further, neuro-imaging research has consistently revealed that the medial-temporal lobes andhippocampus are directly involved in mediating this type of memory [1618] andthat the pre-frontal regions also play a part [19, 20]. However, none of this research

looked at explicit memory functioning in everyday contexts.So far, few studies of children with TBI have investigated implicit memory,

which requires no conscious awareness and, when assessed, attention is not drawn toprior learning events [12]. Implicit memory mediates such processes as conditioning,priming and procedural learning. Shum et al. [14] conducted one of the two knownpublished studies. They found that 12 children with severe TBI learned to identifypictures of objects from fragments (visual priming) at the same rate as a controlgroup. However, those with TBI demonstrated poorer recall (explicit memory)than the controls when alerted to the cues at the time of testing. The otherstudy, by Ward et al. [15], found that children with moderate-to-severe TBI learned

both cognitive and motor-perceptual procedural tasks (mirror reading and rotarypursuit respectively) at the same rate as a control group. Despite this retained abilityto learn mental and motor skills, those with TBI were less able to recall or recognizewords and objects associated with the procedural tasks, even when reminded of thecues. These findings are consistent with those reported in the adult TBI literature[2123] and demonstrate that, while explicit memory may be impaired after a TBI,implicit memory can be preserved. A possible explanation for this explicitimplicitmemory dissociation may be that different areas of the brain mediate these two typesof memory. While the temporal and frontal regions of the brain appear to mediateexplicit memory, diverse inferior and posterior regions appear to mediate implicit

memory. For example, Jennett [24] and Saint-Cyr and Taylor [17] report the role ofthe basal nuclei in perceptual-motor learning, while Gabrieli et al. [25] suggest that

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This type of memory mediates such things as remembering to pass on a message tosomeone when you see him or her and arriving for an appointment at the righttime. Given that prospective memory research is relatively recent, it is not surprisingthat it has not yet been studied in paediatric TBI. However, it is important to

investigate this area for both practical and psychological reasons. From a practicalpoint of view, Graf and Uttl ([27], p. 1) stated that [prospective memory] break-down may be as debilitating as impairments in retrospective memory becauseprospective memory loss has implications for a persons ability to live independently.For instance, if people regularly forget, due to brain impairment or ageing, to switchoff appliances or turn up for doctors appointments, they need to be supervizedby others and, therefore, may lack independence [28, 29]. In the case of children, ifthere were impairments in prospective memory, deficits could result in their failingto become independent of their parents as they mature. From a psychological pointof view, adults with TBI have reported greater concern about forgetting future

actions than about forgetting facts [30]. Their heightened concern about prospectivememory loss over retrospective memory loss could occur because when retrospec-tive memory fails, the memory is seen as unreliable, but when prospective memoryfails, the person is seen as unreliable [31]. Because prospective-memory research is sorecent (the first book devoted entirely to the topic was published in 1996 [32]) and,therefore, is discussed less than other types of memory in general memory texts, it isimportant to explain prospective memory more fully here.

Kvavilashvili and Ellis ([33], p. 25) described prospective memory as: remem-bering to do something at a particular moment in the future, or as the timely exe-cution of a previously formed intention. Prospective memory requires the ability to

integrate complex, goal-directed behavioural sequences that enable individualsto fulfil their intentions in a meaningful order and at the appropriate time [28].Brandimonte (cited in Passolunghi et al. [34]), proposed that there are six phasesin the process of prospective recall: (1) formation of an intention; (2) rememberingthe intention (i.e. remembering what to do); (3) remembering when to do it;(4) remembering to perform the action; (5) actually performing the action in thetime, place, and manner prescribed; and (6) remembering that the action wasperformed after it has been completed.

Two important features of prospective memory are that it comprises bothprospective and retrospective components and that individuals must identify the

appropriate cues for themselves without reminder. For example, if as you dress forwork in the morning you form the intention to stop at the store on your way hometo buy bread and milk (assuming this is not a routine task), you must rememberseveral things, including to stop at the store when you get there (prospective com-ponent) and that it is bread and milk you need to buy (retrospective component).When approaching the store, there is nothing to alert you to pay attention to thiscue. You must appreciate its relevance without anyone to remind you [35].

Another quality of prospective memory, which Einstein and McDaniel [26]believe distinguishes it from retrospective memory, is that prospective memoryoverlaps with other cognitive processes, such as planning and monitoring, and

with non-cognitive ones, such as personality attributes. Winograd [31] concurred,claiming that psychological variables such as personality, motivation and compliance

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This implies that it is not only the strength of a persons memory that determineswhether he will remember, but also how motivated he is, what importancehe places on fulfilling plans, how able he is to plan or how willing he is to complywith an experimenters requests. However, not everybody believes these non-

memory features interact exclusively with prospective memory. For example,Graf and Uttl [27] believe this interaction is just as likely to occur with retrospectivememory as it is with prospective. This debate will be followed up later in theDiscussion.

The present study aimed to: (a) gain insights into the nature and extent ofmemory deficits in paediatric TBI; (b) ascertain the effects of deficits on everydaylife; (c) discover whether families use their own interventions; and (d) determine theefficacy of these interventions in alleviating disability. This study focused on all threetypes of memory noted previously. The investigation could have been exploredin a laboratory setting, which would have offered greater control. However, it

was conducted in the field using a phenomenological approach for several reasons.First, much data obtained so far on the effects of paediatric TBI on memory havebeen derived from objective tests and experimental studies [4]. Thus, the resultsmainly show whether participants succeed or fail to meet particular behaviouralcriteria. They do not indicate the meanings of these behaviours in terms of howthey affect childrens functioning in everyday life. For instance, a quantitative meas-urement of memory that indicates a memory deficit does not necessarily showwhether that impairment translates into a disability or handicap in the real world.Nor do quantitative data collected over one or two sessions provide a dimensionalperspective on how memory functioning might vary from circumstance-to-

circumstance, or from day-to-day [36]. Further, there is evidence that laboratorystudies of young childrens memory can underestimate their capacities. For example,Baker-Ward et al. [37] reported, in a study of normal memory development, thatpre-schoolers recall of toy objects during laboratory testing was poor. However,after testing, the children were able to list in correct order the names of all the otherchildren who were to appear in the testing room. This information had beenacquired incidentally and was reported spontaneously. By contrast, Ewing-Cobbset al. [4] stated that the results of standardized memory tests may overestimate theabilities of children with TBI. Overestimation of day-to-day abilities could occurbecause most commercially available standardized tests of memory assess discrete

functions and children are generally assessed in a one-on-one situation. However,it is much more likely that deficits will be apparent in real life because thosesituations require more focused and divided attention, the generalization ofpreviously learned information and retention of information over longer periodsof time.

Secondly, as previously stated, most data on the effects of paediatric TBI onmemory have been derived from studies of explicit memory, with little explorationof how paediatric TBI affects implicit or prospective memory. Consequently, theknowledge base is limited. To widen the knowledge base on the effects of TBI onchildrens memory functioning, a broad-brush approach was adopted in this study.

Qualitative methodologies are the best means of gaining a broad view because adiverse range of issues can be explored at one time [38].

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this information because, although the data could have been obtained by question-naire, information received via questionnaire is constrained by the content of thequestions asked [39]. The content of the questions in turn is constrained by theexisting knowledge base, which is limited in this instance. As a valid alternative,

parents were asked open-ended questions designed to elicit detailed informationabout whether or not their children have memory failures, the most common typesof memory failures and the circumstances under which forgetting occurs.

Parents, rather than their children, were interviewed because parents wereregarded as more reliable judges of their childrens memory functioning thanwere the children themselves. Clearly, if the childrens memories are poor or ifthey lack insight into their actions, they may fail to acknowledge lapses made andmay report their memories to be better than they actually are [39, 40]. Lack ofawareness of the effects of injury has been reported in several studies of childrenwith TBI (see for example Jacobs [41] and Lazar [42]). Further, children with TBI

could suffer language impairments or have insufficiently developed language skillsto express themselves adequately.

Method

Participants

Thirteen custodial parents of children and adolescents with TBI took part in face-to-face interviews. Eleven were mothers and two were fathers. Participants wererecruited through the paediatric brain injury rehabilitation clinics at the Royal

Childrens and Mater Misericordiae Childrens Hospitals, Brisbane, Australia. Listsof consecutive admissions of children with TBI were compiled. Hospital staffphoned parents who lived within 2 hours drive of Brisbane in order from theselists. When 13 agreed to be interviewed, information sheets and consent formswere posted to them.

The sample of 13 parents was deemed to be both manageable in number, giventhe large volume of data gathered in interviews, and adequate in representation,given that the children were reported by hospital staff to be a relatively hetero-geneous group in terms of current age, age at injury and the site and severity ofinjury.

Note that, after interviewing parents, the principal researcher consulted thechildrens medical records to categorize the children into one of three severitygroups: mild, moderate or severe. The categories were based on specific referencesto the severity of the injuries noted on medical charts. If, however, no specificseverity diagnoses were noted on the childrens charts, their injuries were catego-rized according to severity criteria established by Fletcher et al. [43]. Specifically,those with mild TBIs (n 3) had (a) admission Glasgow Coma Scale (GCS [44])scores of 1315; (b) no radiological evidence of mass lesion, brain swelling or skullfracture; and (c) loss of consciousness of less than 20 minutes. Those categorizedas having moderate TBIs (n 3) had (a) admission GCSs of 912; or of 1315 when

complicated by skull fracture; (b) mass lesion; or (c) other indications of specificbrain injury. The severe group (n7) included those with GCSs of 38. Table 1



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Table 1. Nature of injuries of children and adolescents with TBI whose parents w

Patientnumber Gender

Age(years)

Age atinjury(years)

Intervalbetween

injury andinterview(months) Nature of injury Severity

GCSscore on

admission

Lengthtime ihospit(week

1 F 14 6 101 Pedestrian-vehicleaccident

Severe 45 17

2 M 16 8 82 Pedestrian-vehicleaccident

Severe 34 12

3 M 14 12 22 Motorbikeaccident (farm)

Severe 7 4

4 M 12 8 48 Trail bikeaccident

Severe N/I* 8


Severe 7 2


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Severe 6 3

7 M 13 4 105 Fall (5 m) Severe N/I* 2

8 M 10 9 17 Passenger,motor vehicleaccident

Moderate 13 2

9 M 10 7 33 Fall frommotorbike(in driveway)

Moderate 15 2

10 F 9 8 15 Fall (4 m) Moderate 13 2

11 M 12 8 52 Assault Mild N/I* Nil


Mild N/I* < 1

13 M 14 8 74 Bicycle-vehicle Mild N/I* 2 (fractufemu

*N/INot indicated; ** LOCLoss of consciousness.


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the time of the study, all of the children were at school. Nine were at government-funded public schools, three at privately-funded church schools and one was beingschooled at home by correspondence. Table 1 shows a summary of the childrenscurrent ages, gender, age at injury, injury severity and pertinent details from their

medical charts about their injuries.

Design and procedure

Prior to the interviews, most parents (except four, whose children had beenparticipants in a previous research project) were unknown to the principalresearcher. Further, it was decided not to consult the childrens medical chartsuntil after the interviews. Having limited knowledge of the families and of thechildrens injuries was deemed to be helpful in minimizing interview bias and,therefore, maximizing the validity of the data.

All data concerning the day-to-day memory functioning of the children wereobtained from parents during interviews. After rapport building, to obtain somebackground and establish a context, parents were asked about their childrens pre-injury developmental history and circumstances surrounding the injuries (e.g. how,where and when the injuries occurred). There were no pre-determined questions.Parents were free to tell their stories in their own way. However, after a period oflistening by the interviewer, the conversation was moved towards the topic ofmemory functioning by asking parents open-ended, critical-incident questions, suchas: Tell me about a recent situation when your child forgot something that affectedhim significantly or had consequences for you or others. Follow-up questions were

unstructured. The questions needed to be spontaneous to respond appropriatelyto what parents were saying. For instance, the questions might have been: Howoften does that happen? or How does that compare with your other childrensbehaviour?. Six of the 13 parents (parents of patients 1, 3, 7, 8, 11 and 12) inter-viewed were very well prepared for the sessions. They had observed their childrensmemory functioning closely over the preceding days or weeks, taken copious notesand, in one instance, asked the childs teacher for information as well. These sixparents provided completely unsolicited data on most topics. However, to ensure allthree memory categories (viz., explicit, implicit and prospective) were explored andto assist less well-prepared parents who reported memory failure by their children,

but were unable to think of examples, forgetting cards were given to all parents.These cards were provided mainly as memory cues to help parents recall their ownchildrens instances of forgetting. Twenty-one cards comprising seven exampleseach of memory failures in the three domains of memory of interest were shuffledso that parents viewed them in random order. Examples of statements illustrative ofexplicit, prospective and implicit forgetting were respectively:

. Forgets where he puts things, or loses things frequently.

. Forgets to take one-off items to school (e.g. permission slips).

. Forgets learned patterns or sequences (e.g. a route to a familiar place).

See table 2 for a full list of illustrative examples noted on the cards.All parents, including those who had been well prepared, looked at all cards.

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forget; (3) re-read the cards in the forgets category; and (4) either used theexamples of forgetting noted on the cards as cues to trigger their own examplesof forgetting or indicated, yes, thats an example of something my child forgets;and (5) elaborated on the instances of forgetting (e.g. frequency and circumstances).Non-prepared parents followed the same procedure, excluding step (1). Note thatall 13 parents, after considering the examples written on the cards, were quitedefinite about whether these examples of forgetting applied to their children or not.

Parents were interviewed either in their homes or at Griffith University for 2 hours. With their consent, the interviews were audiotaped. Data were analysedusing the principles of content analysis. This involved: (1) listening to the tapes;

Table 2. List of scenarios presented to parents on cards, which illustrated three types of forgetting:explicit, implicit, and prospective

Explicit Implicit Prospective

Cant remember all the itemson a short list Seems to forget learnedpatterns or sequences (e.g.a route to a familiar place)

Forgets to take one-off itemsto school (e.g. permissionslips, money for excursions)

Forgets what he or she did aweek ago

Has difficulty following a setroutine (e.g. getting readyfor school)

Doesnt remember to passon messages (e.g. phone,teachers)

Forgets what he or she didyesterday

Leaving aside physicaldisabilities, my son ordaughter seems to haveforgotten how to performsome physical or motortasks that he or she could do

before (e.g. kick a ball, ridea bicycle, use a computermouse, play a musicalinstrument)

Forgets to do school projectsor assignments

Has trouble rememberingfacts or details forschool examinations

Has difficulty following therules of games (e.g.computer games, boardgames, sport)

Forgets to turn up toappointments, either at allor on time

Finds it difficult to rememberpeoples names

Finds it difficult learning fromnegative consequencesexperienced in the past (e.g.avoiding a dog that bit

him/her)

Forgets to do important,non-routine chores (e.g.feed a pet)

Cant remember the names ofcharacters from his or herfavourite book or film

Finds it difficult learning frompositive consequencesexperienced in the past (e.g.repeating a behaviour forwhich he or she was praisedor rewarded)

Forgets to turn off applianceswhen finished using them

Has trouble recognizingpeople he or she hasmet recently

Finds it difficult to learn setpatterns or sequences (e.g.speech patterns, spellingrules, musical rhythms)

Forgets family membersbirthdays



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meaningful patterns and processes; and (7) considering identified patterns in the lightof previous research and theories [38]. Note that the analyses generally proceededin the order listed (i.e. steps 17). However, the steps sometimes overlapped orproceeded in a backwards direction when, for clarification purposes for instance,

the tapes needed to be replayed. Step 3, coding, involved naming or articulatingwhat was perceived to be happening in an incident described. This incident wasnamed and its name or label represented the interviewers interpretation of whatwas occurring in that incident. In the early stages of analysis, a given incident waslabelled in as many different ways as could be extrapolated. This brainstormingof possible interpretations ensured the broadest possible thinking about theincident. Later, the incidents ultimate meaning was decided through contrastand comparison with other data (i.e. after steps 5, 6 and 7 of the process of contentanalysis; [45]).

Results

Parents descriptions of their childrens memory functioning were classified withinthe following major themes: (a) memory functioning in general; (b) prospectivememory; (c) explicit memory; (d) non-memory variables such as personality attrib-utes and motivation; (e) implicit memory; and (f) intervention strategies used byparents. Data from one parent were excluded from the analyses because duringthe interview it was discovered that the child (patient number 6 in table 1) had apre-morbid learning, developmental or intellectual disability that made it difficult tocompare pre- and post-injury functioning. Despite this adolescents medical records

indicating that he had suffered a severe TBI, his mother noted that she was unableto tell whether her sons cognitive functioning, including memory, was worse (orbetter) since his brain injury. Ironically, she commented that her son appeared tobe more stable emotionally since the injury. She attributed this to his now havinga recognizable excuse for being slow. All other 12 parents reported that, prior toinjury, their children had normal cognitive functioning and had met all develop-mental milestones at appropriate times. These parents reported that they couldconfidently compare pre- and post-injury functioning.

Note that, in table 1, the childrens and adolescents injuries are listed as severe,moderate or mild. However, given the small sample size, the injuries are hereon

described as either minor, which combines the mild and moderate categories, orsevere, based on distinctions described by Kibby and Long [46] in their review of theliterature on minor TBI.

Memory functioning in general

Table 3 gives a summary of memory difficulties reported by the 12 parents whosedata were analysed. The memory problems are categorized as: Overall MemoryFunctioning; Prospective Memory, Explicit Memory and Implicit Memory. Thetable also includes the childrens and adolescents patient numbers, as listed in table 1,

to help identify which young person is being described.All participants reported some memory problems among their sons and daugh-

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Table 3. Summary of memory difficulties reported for 12 children an

Patientnumber* Gender

Injuryseverity Overall memory functioning Prospective memory loss E

1 F Severe Very poor; memory problemsrated as greatest impairment

Severe; affects functioning S

2 M Severe Very poor; memory problemsrated as greatest impairment

Severe; affects functioning S

3 M Severe Good Minor; only difficulty reportedwas occasional failure to passon messages

M

4 M Severe Very poor Severe; affects functioning S

5 M Severe Good Minor; although, falling behindin spelling because forgets tobring home spelling lists

M

7 M Severe Very poor Severe; consistent failure incancelling intentions

S

8 M Minor** Good Minor M9 M Minor** Good Minor M

10 F Minor** Moderately good, but withsome inconsistencies

Moderate M

11 M Minor** Poor; inconsistent; fluctuating Minor P

12 M Minor** Very poor; memory problems

rated as greatest impairment

Moderate S

13 M Minor** Very poor Severe S

* Patient numbers correspond with those listed in table 1. Note that details of patient 6 have been omitted as this adole


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and who was 14 at the time of interview, stated: I think I now take note moreof what [my daughter] remembers, as that stands out because so much else isforgotten. Another said that her son (patient 12) can remember one thing at atime, but has trouble with more than one. For instance, if she tells him to turn the

volume down on the television and to do something else as well, she stated that,You can see him walking around and looking up as if to ask, What do I have todo, turn the TV down and what else?. Of the other nine participants, five saidtheir childrens (patients 4, 7, 10, 11 and 13) forgetting was a problem, but thatfactors such as poor motivation, aggression or mood disorders were of equal con-cern. The remaining four parents commented that, although their children (patients2, 5, 8 and 9) sometimes forgot things, these memory slips were not serious enoughto interfere with their day-to-day functioning.

Prospective memory

All parents reported prospective forgetting (i.e. forgetting future intentions) bytheir children, although those who said their children were functioning well (i.e.the parents of patients 3, 5, 8 and 9), described the forgetting as not significant.Interestingly, two of the children (patients 3 and 5) said to be remembering quitewell prospectively had experienced severe TBIs. Note, however, that, despite themother of patient 5 saying that her 9 year-old sons prospective remembering wasquite good, she stated at a later stage during the interview that her son was fallingbehind in his spelling at school. When the interviewer followed up on the issue ofthe boys spelling difficulties, the mother stated that her sons problems with spelling

were not due to difficulties with spelling per se, but to his repeated failures toremember to bring home his word lists for spelling practice. It appeared, after all,that he was experiencing some difficulties with prospective remembering, at leastin one area.

Typically, prospective-memory failures involved the children forgetting to takeitems to school, pass on messages, do chores and keep appointments at the appro-priate times or without reminders. The mother of one of the children in the sample(patient 1) mentioned how dependent her 14-year-old daughter is on her as aconsequence of having impaired prospective memory. She said, [my daughter]depends on me for a lot of things. For example, she wouldnt say, Have you

remembered to pack my excursion money or here is a message from my teacher.She never gives a thought to these things. Similarly, the parents of a teenageboy (patient 12) with a minor injury stated that he passes on messages about gymtournaments days after he was supposed to tell us. Another boy with a minorinjury (patient 13) was said to have such poor prospective recall that his motherfears for his safety while she is at work. She is a single mother and either arranges forhim to visit friends or phones him regularly from work to check that he has not, forinstance, forgotten to switch off the stove. She said, I stay on the phone while hedoes things. Equally stressed by her sons prospective-memory failures is a motherof a severely injured 12-year-old boy (patient 7). She said he frequently leaves for

school with his lunch left on the kitchen bench and fails to take messages, consentforms and homework. His forgetting these intentions caused her to rant and rave at

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all the appropriate articles the evening before, but forgets that he has done so andthe next morning searches everywhere for the missing items. When he cannot findthem he screams and kicks his bedroom wall in frustration. It seems the stages ofprospective recall as described by Brandimonte [34] are achieved successfully except

the sixth and final stage that involves cancelling the intention once it is acted upon.Given that researchers have suggested a relationship between prospectivememory and executive functions [4750], it is not surprising that several parentsreported their children having difficulties with executive-type processes. Inparticular, patients 1 and 2, who were both reported to have severe prospectivememory impairments, were also reported to have severe impairments in executivefunctions. For example, patient 1 has problems reading subtle non-verbal cues. Sheinterprets quite literally innuendo and sarcastic tones directed towards her by otherchildren. Her mother said that these upset her, but not her daughter because theirmeanings were lost on her. Similarly, she has difficulties with discourse, either in

initiating or maintaining conversations or understanding humour that involves themanipulation of language. Given that she reads well and writes her own stories, herproblem appears not to rest in the mechanics of language, but in its freeformexpression where spontaneity depends on the ability to integrate social cues andnuances. In addition, patient 1 was said to have trouble planning and organizingeven the most basic tasks.

The mother of patient 2 presented a similar story. Her son, aged 16 at the timeof interview, undertook his schoolwork by correspondence, which requires goodplanning and a systematic, logical approach to problem solving. His mother usedto help him organize his study material and do a study plan. He seemed to manage

quite well with her assistance. However, when he reached an age that she thoughthe ought to be able to do this for himself, he fell way behind with his reading andassignment work because he seemed unable to manage all the information. Hisinability to plan and integrate information at the age his mother expected him to beable to could be the case of a child growing into a problem as he matures.

Explicit memory

Seven parents reported that their children (patients 1, 2, 4, 7, 11, 12 and 13) had

difficulty remembering facts and events when they were reminded specifically of thelearning occasion. Again, this explicit forgetting applied to children with severeand minor TBIs. A particularly salient example of this type of memory disabilitywas experienced first hand by the primary researcher. On arriving at the familyshome, she was met by the 16-year old (patient 2) with a severe TBI. Six monthspreviously, the researcher had worked for 2 hours on a one-to-one basis on a dif-ferent research project with the young man. She recognized him instantly, butwhen she asked if he remembered her or the occasion he said No, and indeedthere was nothing in his manner to indicate any recall or recognition.

The mother of a son with a minor TBI (patient 13), aged 14 at the time of

interview and injured at age 8, stated that he: Cant remember what hes justread. And he likes to build things, but keeps forgetting where hes put the tools.



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Several parents reported that their children (patients 1, 4, 5, 11, 12 and 13) haddifficulty remembering when asked to recall outright, but could remember if theywere given prompts or were asked to recognize rather than recall. The failure ofdirect recall, but success of cued recall and recognition suggested that the children

were encoding the information, but were having trouble retrieving it. In the wordsof one mother (of patient 1): Its all in there but she cant pull it out. However,the same parent later commented that: Some things she cant recall, even with lotsof reminders. This failure to remember, despite being cued, suggested thatthere were at least occasional encoding problems, which was reinforced by thefact that three children (patients 1, 11 and 12) were reported to encode withouttemporal or contextual markers. For instance, the mother of patient 1 describedhow an incident might occur and she and her child would discuss it at length. Then,2 weeks later the child would say, Guess what, Mum . . . and relate the sameincident as though it had just happened and the mother knew nothing about it.

Two other parents, both of children with minor injuries (patients 11 and 12),reported similar phenomena. One said that her son (patient 11) forgets what hewas doing yesterdaynot the event, but the sequence and context in which itoccurred. The other (parent of patient 12) said, He sometimes remembers some-thing, but cant remember when it happened.

Explicit memory functioning was also described as variable or fluctuating. Themother of patient 11 said Its like a light bulb going on and off. He cant remembernames of characters from books, et cetera, though this is intermittent. He will forgettoday, but remember tomorrow. Some children were also said to retain certain factsand events and not others. The girl with the severe TBI (patient 1), for example,

was reported to be quite good at remembering numbers (e.g. birthdays, telephoneand school identification numbers) and the words of songs she liked, but usuallyforgot what she did on her visits to her father, where she had been a week ago andthe names of people she had just met.

Non-memory variables: explicit and prospective memory

Several parents reported non-memory factors (e.g. planning and organizing andmotivation) overlapping with their childrens ability to remember. The overlappingseemed to occur mainly with prospective, but also with explicit remembering. In

terms of organizing, there was the case of the boy (patient 7), already referred to,who packs his sports equipment the night before required. Unfortunately forhim, despite his pre-planning, he fails to remember that he has already executedhis plan. Another boy, with a severe TBI (patient 3), does a similar thing, though hisefforts are more successful. His mother reports that he plans out his school-related commitments in advance and either writes himself notes and lists or askshis mother to do it for him. Consequently, he never forgets to take messages toschool, to complete assignments on time or to take consent forms back and forthbetween home and school. However, he often does forget to pass on telephonemessages, possibly because these are unplanned, falling outside the regular weekly

schedule.Motivation also appears to make a difference, particularly with prospective

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motivated when it comes to doing things for food. Although this adolescentoften forgets what happened 10 minutes ago and seems generally unable to antici-pate the future, she will remember that they are going to town the followingweek because her mother promised she could have an ice-cream when they got

there. Similarly, her support teacher noted, in typed comments given to the girlsmother, that the child usually remembers she has tuckshop (food takeaway days atschool) without prompting. Further, she reminds her mother to give her moneyfor tuckshop, even though this only occurs once every fortnight. Moreover, shenever forgets to take cooking ingredients to school for home-economics classes.This specialized prospective remembering is also noted in the 16-year old boywith a severe TBI (patient 2). His mother reported that he generally forgetsroutine and one-off appointments, to pass on messages and to hand in schoolassignments on time. However, he never forgets his appointment with hispsychologist. Apparently he likes and trusts his male therapist and looks forward

to his visits. His motivation could also be related to his family situation. Helives with his mother and step-father, with whom he quarrels a great deal, andrarely sees his biological father. Having the opportunity to spend time with anempathic, supportive father figure may be a strong incentive to remember theseappointments.

Motivational issues also appeared to impact on explicit memory. For example,the girl who loves food (patient 1) not only remembered to take her cookingingredients to school on the right day, her mother says she can still rememberthe next day a lot of the ingredients she had used. She enjoys music as well. Thismay explain why she also remembers the words to her favourite songs.

Implicit memory

Few children were reported to have implicit memory impairments, including thosewith the most severe injuries, one of whom (patient 1) was said to take a little whileto learn new skills (e.g. puzzles and simple board games), but once she learns them,doesnt forget. Her learning-support teacher, again, in written comments given tothe girls mother, confirmed this by stating that when the child had to change roomsor buildings at school, she took a while to learn the new routes, but once established

was able to find her way without getting lost. And her mother reported beingsurprised that her daughter found her way to her fathers house on her own oneday after having been accompanied by her older sister on all previous occasions.However, one parent did report her son (patient 7) having difficulties with follow-ing set routines. Possibly the procedures he failed to learn were more complex thanthe ones he remembered or perhaps he failed because he was rushed (e.g. in themornings before school). Interestingly, two parents also expressed concern that theirchildren (patients 4 and 7) may not learn from negative consequences, that is havepoor associative learning (implicit learning), and might, therefore, take unnecessaryrisks. It is possible, however, that risk-taking behaviour might not be due to a failure

of implicit memory, but to impulsiveness or a failure to inhibit responses. In otherwords, these children might repeatedly behave in ways that elicit unpleasant



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Intervention strategies used by parents

Six parents described strategies that have helped with their childrens (patients 1, 2,3, 4, 5 and 7) remembering. Some of these strategies were devised by parentsin direct response to recurring problems. Others were suggested by rehabilitation

professionals, but adapted to suit the childrens unique circumstances. Strategiesincluded employing: (1) negative reinforcement, a form of operant conditioning;(2) rhyme and rhythm; (3) repetitive routines; (4) external aids; and (5) scaffolding, ametacognitive technique whereby problems are broken down into components.Two parents described using negative reinforcement, the use of which is illustratedin the case of patient 2, who kept forgetting to return rented videos. His motherincurred great expense paying his overdue fines and gave her son an ultimatum. Ifhe was late in returning them and a fine accrued he would have to pay out of hispocket money. This strategy worked immediately. From that point on, he remem-bered to return the videos. Similarly, the mother of patient 1 told her daughterthat she was allowed to ask her mother the same question twice. After the secondanswer, the girl had to write the answer down on a piece of paper and was notallowed to ask her mother a third time. The daughter was thought to put moreeffort into remembering because she found that easier than having to find a notepadand pen to write things down. Of course, there is a possibility that these childrenwere not forgetting these things in the first place, but had simply got into the habitof having their parents do things for them. Perhaps the negative reinforcementwas not teaching remembering, but teaching them to take back responsibility forthemselves.

Another strategy was to employ rhyme and rhythm in teaching conversationalskills. One mother used this. Her daughter (patient 1) had difficulty respondingappropriately to polite inquiries about her welfare so her mother made up a set ofpat responses like lyrics to a song, then set them to the tune of Waltzing Matildaand sang them to her over and over. The mother said her daughter could rememberthese patterned, rhythmical phrases much better than she could if she had beensimply told them.

Three parents said that establishing a repetitive routine for the execution ofchores helped their children (patients 1, 5 and 7) to remember. For instance, onemother typed up and posted a list of chores for her son (patient 5) to complete every

day. As he completed the chores, he had to strike them off the list. His mother keptup this procedure every day for 3 months. She reported that now he has memorizedthe list and takes great pride in informing her as he completes each task. There aresome difficulties with this repetitive learning, however. The routines can becomeso entrenched they are nearly impossible to undo. The unlearning of reinforcedresponses proved to be difficult in the case of a child (patient 1) who learned a setregime for taking medications. When the prescriptions changed, the mother hadgreat difficulty getting her child to break the old routine.

Four parents declared trying external memory aids with their children (patients1, 2, 3 and 7). One of these parents said that external reminders were helpful to her

son (patient 3), who was reported earlier to write himself notes and lists to help himremember school commitments. His school had helped too in colour-coding his

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memory was failing and if they were motivated, they might remember to consulttheir notes or lists. Conversely, if children were not conscious of forgetting,they would not know there was a need to use aids and would, therefore, notcomply [51].

A strategy to help with problem solving was described by one mother. She useda scaffolding-type procedure. When her son (patient 4) had a complicated taskto perform, she would break it into manageable portions for him, explainingthe logical sequences, that is that Step 1 had to be completed before Step 2. As theboy often had trouble knowing where to start, she would say, I think it will workbest if you do this first. What do you think? She said that once she got him started,he could usually follow through, so she would let him proceed until he neededsome further guidance. She found that, with this technique, he took more initiativeand depended on her less as his prosthetic frontal lobe [52].

Overall, intervention strategies were devised by trial and error. When something

was tried and appeared to work, parents tended to reuse it, possibly adapting andrefining it as they went along. The process required them to have good observa-tional skills, to put in a lot of effort and to be very patient. However, they believedtheir endeavours were worthwhile because, when they found a strategy thatworked, it improved their childrens everyday functioning and lessened the burdenon the family, even if only in small ways.

Discussion

Four main conclusions can be drawn from the parents reports. First, prospective

memory failure was both frequently reported and said to cause the most stressand concern among parents. Further, person-attribute variables such as levels ofmotivation overlapped with prospective recall, although there was also evidenceof interaction between motivation levels and explicit recall. In addition, althoughpre-planning enhanced prospective recall, the planning did not always help ifthe intention to act could not be cancelled once the action had been performed.Secondly, of the two types of retrospective memory, explicit was frequentlyimpaired and implicit generally preserved among the children. Moreover, explicitmemory functioning was variable, with inconsistencies in performance noted overtime. Thirdly, family-devised rehabilitative strategies helped improve memory

performance or compensated for memory losses. Finally, severity of TBI amongthe children did not necessarily match the severity of memory dysfunction reported.These findings will now be discussed.

Regarding the frequent reporting of impaired prospective memory and itsrelated effects on everyday functioning among the children, there is no empiricalsupport from elsewhere, because, so far as the authors are aware, the current study isthe first study to investigate prospective memory in children and adolescents withTBI. However, there is some concurrence with studies of prospective memory inadults with TBI. For example, Shum et al. [53] reported more prospective forgettingin adults with TBI than in a control group on an experimental task where

participants were required to answer general-knowledge questions from a computerscreen. Throughout the process, the computer presented the participants percen-



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demonstrated impairment in those with TBI across the range of prospectivememory tasks.

In the current study, parents reported not only a high incidence of prospectivememory failure, but also significant negative consequences of the forgetting

for themselves as caregivers. Even among some of the adolescents, who mightordinarily be expected to be mature enough to remember appointments, pass onmessages and switch off appliances, parents were having to take the responsibilityof remembering these things on their childrens behalf. However, certain non-cognitive variables were found to overlap with the childrens prospective recall.For instance, in some circumstances where children were rewarded for remember-ing by achieving some positive payoff, their motivation to remember appeared tobe able to overcome cognitive limitations, even in the case of children with themost severe TBIs. These findings of remembering when motivated tend to supportwhat has been found in research on prospective memory in general populations

[26, 31, 39].Note though that motivation to remember seemed also to apply to explicit

recall, and suggests that Graf and Uttl [27] may be correct in arguing thatperson-attribute variables overlap as much with explicit as they do with prospectivememory. Note also that motivation might affect forgetting as well as remembering.Specifically, the fact that children failed to turn up for dental appointments or to dohomework may not have been the result of prospective memory deficits, but simplyof a desire not to do these things. One further point regarding motivation that isworth considering is its relationship in some instances to operant conditioning,in particular learning through positive and negative reinforcement (e.g. receive an

ice-cream or avoid paying fines if I remember). The motivation-conditioningrelationship could involve so-called somatic markers which, according to Damasioet al. [54], are links mediated by the ventromedial pre-frontal region betweenknowledge and emotions and which allow people to learn from experiences thatinvolve positive or negative consequences [7]. Therefore, although motivation toremember is essentially an emotional rather than a cognitive phenomenon, theremay be cognitive elements involved. Further investigations of this may shed morelight on this possibility.

In some instances children were highly self-aware of their intentions to actand pre-planned to avoid forgetting. Pre-planning was successful for some, but

not for others, however, as was the case with the adolescent who seemed tohave to keep his intention alive because he forgot that he had already acted tofulfil the intention. His case demonstrates the complexity of prospective recall andthat it cannot be assumed that just because an intention is kept in mind and actedupon at the right time, the process is complete. Unless, after one has acted, oneremembers that the action has been performed, the intention is kept in mindcontinuously, making demands on cognitive resources needlessly.

Parents statements about their childrens difficulties with executive functions areimportant to report here because of a proposed link between prospective memoryand executive functions [4750]. Intuitively, a link seems plausible given that, with

prospective remembering, intentions have to be held in mind, monitoring for cueshas to occur and switching from one task to another is required. These processes are

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If there is a relationship between prospective memory and executive functions, itmay exist because both are mediated by the pre-frontal areas. In fact, Shimamuraet al. [49] state that pre-frontal damage may lead not only to executive systemdeficits but also to impairments in prospective memory. Indeed, Shallice and

Burgess [48] showed a positive relationship between prospective rememberingand performance on planning and decision-making tasks in adults with pre-frontallesions. However, few researchers have yet tested this pre-frontal modelof prospectivememory in children. And, although prospective memory and executive functiondeficits were reported with similar regularity, no conclusions can be reachedfrom these anecdotal reports about a possible relationship between them. Furtherexploration of a relationship needs to be followed up using controlled experimentalparadigms.

The evidence provided here of impairments in explicit memory concurs withthe results of quantitative studies that used tests of free recall, cued recall and

recognition [9, 10, 55, 56]. Similarly, the infrequent reporting of implicit memoryloss in day-to-day functioning tends to support the results of laboratory-basedstudies of visual priming and procedural learning, which found that children withmoderate-to-severe TBI were unimpaired on these tasks compared with controlgroups [14, 15]. Taken together, the parents reports of impaired explicit andgenerally-preserved implicit memory in their children tend to demonstrate theecological validity of a theorized functional dissociation between these two typesof memory. This dissociation was first noted by Cohen and Squire [57] and hasbeen reported consistently since in adults [2123] and children with TBI [14, 15].This functional distinction suggests an anatomical dissociation (i.e. that different

cortical areas mediate the two systems). Indeed, neuroimaging research has revealedthat the medial-temporal lobes, hippocampus and frontal lobes are directly involvedin mediating explicit memory [16, 17, 19, 20]. On the other hand, various inferiorand posterior regions of the brain such as the basal nuclei [17, 24] and the rightoccipital cortex [25] appear to mediate implicit memory. Given that, in this study,most of the childrens injuries were in the pre-frontal and temporal regions, asindeed they are with most cases of TBI [5860], it is not surprising that parentsreported numerous explicit-memory and few implicit-memory problems in theirsons and daughters.

Another report by parents was of variability in explicit recall from day-to-day

and situation-to-situation. In particular, children seemed to be encoding informa-tion successfully at times, but having trouble with retrieval, as was evident fromexamples of children being able to remember when given prompts or cues. Onother occasions, however, perhaps because of attentional lapses or fatigue, encodingseemed to be compromised. Further, parents noted that sometimes their childrencould recall facts and events, but not where or when these occurred, as though theywere encoded without any temporal markers. West [61] argued that this decreasedsensitivity to the contextual distinctiveness of information retained from theenvironment is due to pre-frontal impairment. Milner et al. [19] demonstratedthis phenomenon in an experimental study. They found that patients with

frontal-lobe damage were less able than controls to identify items that occurredmost recently on a test, nor to be able to accurately estimate the frequency of



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between the medial-temporal lobes and pre-frontal regions in mediating encodingprocesses [62].

Rehabilitative strategies employed by parents relied on behavioural condition-ing, for example the use of rewards and punishments. These strategies are

commonly used in children with behavioural problems [63, 64] and in TBIrehabilitation [52, 65]. However, Ylvisaker et al. [7] warn that strategies that relyon consequences may not work in children with damage to the ventromedial regionof the pre-frontal cortex because the neural links between memory and emotionsmay be impaired. If rewards for remembering or behaving a particular way cannotevoke positive feelings in the child, then offering rewards would be a waste of time.

Other interventions used by parents included skills training that is underpinnedby implicit memory [11, 13]. Strategies involved repetition and the learning of setprocedures and patterns. Similar strategies are employed by professionals for teach-ing and training during the period of post-traumatic amnesia [66] and have been

refined in teaching amnesic adults to use computers [67] and in eliminating errorsfrom procedures and routines [68]. However, some caution is needed in employingthese repetitive procedures. If they become over-learned, it may be difficult tountrain the children if the procedures need to change in the future, as was apparentin the case of the child whose medication regime changed.

External memory aids such as lists, written messages and colour-coded plannerswere employed in facilitating prospective recall. These too are commonly utilizedby rehabilitation professionals [69, 70]. However, though many parents tried theseexternal aids, they appeared only to be successful in children with high self-awareness (i.e. conscious of their own difficulties). Other children failed to comply

with these strategies, which tends to concur with findings by Fleming et al. [51].Another procedure used to help planning was scaffolding that involved a carerhelping the child plan out the problem to be solved and filling in details for himwhen he was unable to make connections between parts of the plan. An elaborateversion of this strategy is used with great success in treating those with executivesystem deficits [71]. Note that further study of individual needs and appropriateintervention strategies need to be considered for these children.

One issue to note about the results of this study concerns the accuracy of theparents reporting, which does not imply that parents were lying, but that, becausetheir judgements relied on subjective assessments, they may have overestimated

or underestimated their childrens cognitive abilities. For instance, some parentsof the youngest children (i.e. 9- and 10-year-olds) reported prospective memoryand executive system failures. Unless the parents had a sound basis for comparison(e.g. experience with other children in the family or exposure to other children thesame age outside the family), these reports may be overstated. This conclusionis based on an assumption that the frontal-lobe model of prospective memoryis correct [49] and that the frontal lobes do not fully mature until adolescence[72, 73]. Given the later maturation of the pre-frontal regions, pre-adolescentchildren would be expected to be relatively poor at prospective recall and executivefunctioning, whether neurologically impaired or not. Therefore, children beneath

the age of say 11- or 12-years with TBI, even those with focal pre-frontal damage,should perform on a par with their age peers. Consequently, reports of prospective

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these impairments if their injuries were severe and located in the pre-frontalregions [71].

A further issue to arise from this study was an unexpected relationship betweeninjury severity and outcomes for some of the children. For instance, two young

people with severe TBI were reported to be doing well overall in memoryfunctioning. However, three with minor injuries were reported to have difficulties.Generally, outcomes can most reliably be predicted in the case of those with severeinjuries, where typically, say Kibby and Long ([46], p. 160) residual cognitivedeficits are almost always present. Fortunately, for whatever reason, the twochildren with severe injuries whose outcomes are generally good appear to bedefying the trends. Conversely, the situation is less favourable for those childrenwith minor injuries who were reported not to be remembering well. Possibly,in the case of the boy injured at 2 years of age, the injury, although minor, mayhave been sufficiently serious to disrupt functions during a critical period of his

development. Note that Ewing-Cobbs et al. [4] stated that some of their studiesof language and memory after TBI revealed that skills developing rapidly at the timeof the injury were more adversely affected than well-established skills, despite theseverity of the injury. And in the cases of the other two children whose CT scansrevealed no brain abnormalities, yet who were reported not to be rememberingwell, there could be psychological [46, 74] or other pre-morbid or post-morbidvariables that explain their difficulties [46]. For instance, one of these boys wasallegedly kicked in the head at school and, from his mothers reports, hadexperienced anxiety symptoms since the incident. His psychological state couldalso be exacerbated by the anticipation of a pending court case involving the alleged

assault. The other boy may also experience stress-related symptoms because he isan only child and lives with his single mother who had recently undergone heartsurgery. Although these boys difficulties may have a psychological rather thanorganic basis, it does not mean that their cognitive problems are not real of courseand further follow up is recommended, both in helping these children specificallyand in investigating non-organic factors in TBI-related outcomes in general.

This study has contributed to the understanding of the long-term effects ofpaediatric TBI on memory functioning in a number of ways. First, it showed,possibly for the first time, that TBI affects prospective recall in children andadolescents. Secondly, it demonstrated that prospective memory can fail even

after an intention to act has been fulfilled, in that an individual may forget hehas acted and the intention remains activated needlessly. Thirdly, it showed thatplanning can enhance prospective recall and similarly that motivational or emotionalfactors can overlap with prospective and explicit memory, allowing even those withsevere TBI to successfully remember future intentions and past events and facts.Fourthly, this study revealed how individualized, contextually-appropriate rehabili-tation strategies can improve the day-to-day memory functioning of children withTBI. And, finally, it showed that qualitative research has an important role to play inunderstanding the long-term effects of TBI. Specifically, this methodology was ableto go beyond merely showing whether children succeeded or failed to remember.

It provided an in-depth perspective on the conditions, circumstances and environ-mental variables that impacted on memory functioning and revealed intervention



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judgements, the data may have been imprecise, exaggerated or understated. Forinstance, because of the seriousness of TBI, parents may be overly sensitive to itspossible effects, attributing all difficulties experienced by their children to their headinjuries and ignoring the effects of other factors. Secondly, everyday environments

do not allow variables to be controlled. Therefore, the mechanisms that underliememory failures cannot be identified. For instance, when an event is reported to beforgotten, because the researcher cannot be present at the time the event wasexperienced, it is impossible to determine if the forgetting represents encoding,storage or retrieval failure [37]. A further limitation of this study is its restrictedgeneralizability because it was based on a small, demographically-restricted sample(viz. 12 participants).

Several recommendations are made for follow-up. First, a study with a largersample of children from a broader range of socioeconomic, ethnic, educational andgeographic backgrounds would be informative. Secondly, an in-depth investigation

of minor TBIs would help in determining whether ongoing cognitive difficultiesare organically or psychologically based. The use of functional imaging may beemployed plus the testing for variables such as level of social support and psycho-logical abnormalities. Thirdly, the role that non-memory factors such as planningand motivation play in mediating both prospective and explicit memory would beinteresting to pursue. Understanding the role of non-memory factors would be oftheoretical interest and could also have implications for rehabilitation. Fourthly,regarding rehabilitation, the efficacy of some of the methods employed by parentsin this study could be investigated further to see whether they may have moregeneral applications. Finally, a more controlled study of the effects of paediatric TBI

on prospective memory is warranted. As evidence now exists that brain injury canaffect prospective recall in children, it is important to understand the normal devel-opmental trajectory of prospective memory. A study plotting the development ofthis type of memory could be underpinned theoretically by an investigation of thefrontal-lobe model, wherein prospective-memory performance would be measureddirectly by manipulating variables that are known to be affected by frontal-lobecapacity and indirectly by measuring the relationships between executive-systemand prospective-memory performance.

Acknowledgement

This project was supported by a grant from the Centre of National Research onDisability and Rehabilitation Medicine (CONROD).

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Artigo 1 Traumatic Brain Injury on Memory Qualitative Study