Training Can Improve Learning for Adolescents with Traumatic Brain Injury

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Barrett Whitener: A new therapy promises to shorten the recovery time for young people who have suffered a brain injury. Such injuries have a number of causes, but commonly occur after a blow to the head or even after an object pierces the skull and damages brain tissue. Young people with a traumatic brain injury often recover their basic intellectual functioning and learning ability, but they may have trouble with tasks that require more complex thinking, such as schoolwork, driving, or social interactions. These difficulties may last for years.

Now, researchers have developed a way to shorten recovery time from traumatic brain injury, with a specific kind of training. It’s called “gist training,” and it involves getting the essence from complex information instead of memorizing facts. The term comes from the expression “to get the gist of something”—to extract the fundamental meaning of a conversation or an article while leaving out the details. The training helped a group of young people with traumatic brain injury to significantly improve their ability to excerpt meaning—a skill that is basic to everyday functioning.

From the National Institutes of Health, I’m Barrett Whitener. This is "Research Developments,” a podcast from the NIH’s Eunice Kennedy Shriver National Institute of Child Health and Human Development, the NICHD.

With me today is the study’s lead author, Lori Cook, of the Center for Brain Health at the University of Texas at Dallas. Her study was funded in part by the NICHD. Dr. Cook, thank you for joining us today.

Dr. Lori Cook: Thank you for having me.

Mr. Whitener: How did you develop the concept of gist training, and why did you think it would help those with traumatic brain injury?

Dr. Cook: Well, the gist training work is actually based on work that has been headed up by Dr. Sandi Chapman here at the Center for Brain Health over the course of the last 20 to 25 years. Essentially, this idea is that, from a cognitive science perspective, in terms of learning, we truly are better wired to be gist thinkers as opposed to fact or detail learners. I like to think back to the old saying of “don’t miss the forest for the trees.” Essentially, in this modern age of information overload, folks are typically quite prone to maybe getting so caught up in those details, those trees, that [they] might be missing the very important meaning or gist behind that information. That is certainly a theme that we observed in our young people with brain injury.

So, realizing there are certainly some aspects here that we can train, give them some tools to now transform this learning style into one that is much more top-down, really focusing on let’s get these big ideas first, and it’s going to give those details something to hold onto and hopefully really maximize their learning efficiency and effectiveness.

Mr. Whitener: Now, I thought it was interesting that you also hypothesized, you and your co-authors, that the gist training would improve the subjects’, the young peoples’, ability to recall facts and details, even though this ability was not officially or formally part of the training. Why did you think it might have that impact as well?

Dr. Cook: That’s right. Well, the cognitive science research behind this idea of gist, and we’ve been able to build from some incredible foundations established by researchers such as Valerie Reyna, van Dijk and Kintsch, and really realizing that if we can approach information, again, starting with those big ideas, it can really help give those details some footing.

So, for example, to listen to a story, before you start diving into kind of remembering this piece and that piece, let’s first establish what is the take-home message here? That’s going to give me my big idea. And now let’s evaluate what’s the important information here that all ties to that big idea? And, again, it gives essentially some organization to how information is being taken in, in bigger chunks, if you will, and really allows folks to get rid of what they don’t need so they can dig in deeper to what they do need.

Mr. Whitener: How did you conduct the study?

Dr. Cook: Well, this study was set up as a randomized pilot study. So, we had 20 adolescents. This was focused largely on our teenage learners and middle and high school, and these were kiddos who were in the more chronic phase of recovery. So they were at least six months out from their injury, but were still experiencing certainly some cognitive effects of their injury, and really ranged from our mildly injured—so our concussion sorts of cases—all the way up to some kids who experienced a severe brain injury. And we would randomize them into one of two groups: either a group that received this gist training—and we call it the SMART program, and SMART is an acronym that standards for Strategic Memory and Advanced Reasoning Training. So we are really focusing on this idea of helping them build a more strategic approach to their learning.

And then the other group was focused on some rather rote memory strategies, things that many of us are probably familiar with, things like mnemonics, coming up with mnemonics to help you learn lists, or visualization strategies, using note cards for repetition, things like that. So still some valuable strategies, but very much focused on more fact-based learning as opposed to this gist-based idea.

And so what we did was conduct these trainings one-on-one, eight sessions, 45 minutes, so these were not long, and did those over the course of a month. So, typically we’re saying maybe two afternoons after school for a month, two afternoons a week for a month. And then evaluated, both before and after the trainings, how they did in these higher-level learning skills, as well as other important executive functions that are often very vulnerable in brain injury. And also received some feedback, some standardized feedback from the parents as well.

Mr. Whitener: You mentioned the executive functions. Can you tell us a little bit more about what those are?

Dr. Cook: Sure. So, some of the aspects that can be particularly vulnerable in brain injury are skills that are mediated largely by the frontal regions of the brain, particularly for teenagers. This is a time when the frontal lobes are really kicking into gear and engaging important skills, like planning and organization and reasoning and decision-making, and certain aspects of working memory, the ability to really hold information and manipulate it for problem solving.

And so we administered some standardized measures to get at some of these key skills in isolation, such as working memory. Say, for example, the ability to hold a list of numbers in mind and then repeat them back to me in reverse order. Or inhibition, the skill to be able to control impulses, to stop and think before giving a response. Those were some key areas that we really saw also impacted by this SMART approach to training.

Mr. Whitener: Can you tell us more about what you found with regard to the abstract meanings and the gist reasoning?

Dr. Cook: Sure. So our primary finding was that the individuals who did the SMART training did show after training some remarkable gains, primarily in their ability to abstract these gist-level thoughts. So imagine, for example, one of the primary measures we gave here is, I’m going to read with you three different texts, and let’s say one of these texts reads very much like a history lesson. And after we read this text I’m going to take it away and I simply want you to summarize it for me.

So what we’re instructing them is not to give me a re-tell, don’t just memorize it and tell it back to me, which is what a lot of kind of standard assessments do. Kids with brain injury can actually do [that] quite well. They really compensate to do that—almost a copy, a cut-and-paste sort of memory, if you will, such that typically when you administer that, they’re going to give you back something that’s got some verbatim phrases in it but doesn’t really make a whole lot of sense. It doesn’t tie together. So, that’s why we elicit these summaries. We want to see, can they condense it and really just focus on what’s important, put it in their own words, think about it in their own way, and then in the process really consider, what are some of the bigger meanings here—some of the ideas that really read between the lines.

And that is a skill that we certainly saw some improvement in, which we very much hoped, based on what we were really working on through the SMART training. And interestingly, we did not see those gains in the group that did the memory strategy training. However, again, back to the SMART group, we also saw some spillover gains to some of those key executive functions, like working memory. Even their recall for the facts in the stories improved, even though we were focusing on the bigger ideas.

And in the memory-training group, again, we didn’t see gains in these higher level measures or the executive function measures that we measured directly.

Mr. Whitener: It’s really a remarkable set of benefits that the gist training gave. Can you share any advice based on your findings with parents and caregivers of young people with traumatic brain injury, or any suggestions?

Dr. Cook: Sure. I think first it’s important to keep in mind this idea that a child or a young person with brain injury can really endure some unique cognitive setbacks due to the fact that they have a developing brain. The developing brain is more vulnerable to injury, in that our long-term work here at the Center for Brain Health has really demonstrated this idea of “neurocognitive stall.” In other words, the potential for a young person to really regain quite well the skills that they had already acquired up to the point of injury, but it’s new learning that is most impacted.

So there is—long-term monitoring is really crucial for these kiddos to help identify as they hit these later developmental stages; make sure that they can stay on track and not fall behind relative to their peers as they have to bring on these higher-level skills. So, this is a really important idea to consider that not only can we monitor for these things, but I think most importantly gains can be made at any point after injury.

A lot of individuals are still of this opinion that—or of the misconception that—what you see is what you get once it’s been, say, a year since your injury. And we can absolutely see that that is not the case. We’ve worked with kids who were years out from their injury and were still able to show some remarkable gains given some targeted, evidence-based training, which really provides some hope for positive change in healing throughout the lifespan.

Mr. Whitener: I’ve been speaking with Dr. Lori Cook. She is the lead author of the study “Cognitive Gains from Gist Reasoning Training in Adolescents with Chronic Stage Traumatic Brain Injury,” published recently in the journal Frontiers in Neurology. Thank you for joining us today, Doctor.

Dr. Cook: Thank you very much.

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About the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD): The NICHD sponsors research on development, before and after birth; maternal, child, and family health; reproductive biology and population issues; and medical rehabilitation. For more information, visit the Institute’s website at http://www.nichd.nih.gov/.