Running head: WORKING MEMORY DISORDER INTERVENTIONS

Working Memory Disorders: Best Practices for Developing Interventions for Phonological Loop Deficits Jo Friesen University of Calgary

WORKING MEMORY DISORDER INTERVENTIONS Introduction Memory is a complex cognitive function that is related to numerous cognitive and neuropsychological functions, including language development, attention and executive functioning (Gillam, 1997; Hood & Rankin, 2005). In working with children, the role of memory is of particular importance, as memory disorders in children can have significant long-term implications on their academic achievement, language acquisition and social development (Gillam, 1997). It is important that memory deficits are identified, accurately assessed and that interventions to support children with such deficits are developed using best practices for design, implementation and evaluation. Memory capabilities differ from children to adults, especially in terms of capacity, and these differences need to be taken into account during all aspects of the intervention process (Gathercole & Alloway, 2006). Children have a more limited memory span, which allows them to remember fewer pieces of information at a time (Barry, 2006). They also have developed fewer strategies related to memory and have less cognitive ability to use such strategies, further limiting this capacity (Barry, 2006; Rankin & Hood, 2005). In general, children process information more slowly, and have more limited processing space, meaning less information can be processed at one time (Barry, 2006). Task automatization increases both processing speed and processing space, so these components increase for children not just with development, but through task experience as well (Barry, 2006). This is important to keep in mind for two reasons. First, in determining if a memory disorder exists, a childs actual ability is compared to a certain level of expected performance. In determining that level of expected performance, it is important to look at childs developmental level and the level of functioning of his or her peers, and not base those expectations on what an older child or adult may be able to accomplish. Second,

WORKING MEMORY DISORDER INTERVENTIONS considering all of the academic, cognitive and social abilities that have a memory component, any deficits in memory ability may have a more significant effect on a child who is still developing these abilities (Rankin & Hood, 2005).
The value of providing interventions for children with memory disorders may be clear, but it is also important to ensure that best practices are used to design, implement and evaluate any such interventions. Upah and Tillys (2002) twelve-step process provides a useful framework for working through this process. Their process can be applied to all manner of cognitive, behavioral and academic interventions, and works well for putting together a complete plan for memory disorder interventions. Problem Identification The first stage of Upah and Tillys (2002) process is to identify the problem the individual student is having, primarily through determining how the child actually performs compared to what their expected performance would be. In the case of memory disorders, this would involve determining both what the childs expected memory abilities should be as well as assessing his or her current level of performance (Upah & Tilly, 2002). In order to do this effectively, it is important to have a thorough understanding of typical memory development in children, as well as a general understanding of memory.

Gillam (1997) breaks the memory process into four different phases, all of which are interrelated: encoding, storage, retrieval and reporting. In order to remember new information, a child must first represent that information in their mind (encoding), then hold it to either use immediately or later (storage). They must then be able to access that same information (retrieval) and finally reiterate what that initial information is (reporting) (Gillam, 1997). Memory can also be divided in explicit versus implicit memory. Explicit memory involves information that an individual is consciously aware of and can intentionally recall. This type of memory is flexible and deficits in this area have shown success at benefitting from well-designed interventions (Hood & Rankin, 2005). Implicit memory is more rigid and is related to acquired knowledge

WORKING MEMORY DISORDER INTERVENTIONS such as procedural skills, which makes it more difficult to provide interventions for (Hood & Rankin, 2005). One aspect of memory that has been well-considered in research relating to interventions for children with memory disorders is working memory. Working memory is the part of the process that involves the simultaneous processing and manipulation of information with the goal to preserve the information for immediate or later use (Smith, 2004). Baddeleys (2003) model of working memory divides the process into three components: the phonological loop (which involves verbal information), the visuo-spatial sketchpad (which involves visual and spatial information) and the central executive (which manages the information stored by the other two components). The phonological loop is further divided into two components, the phonological store, which can hold information for a few seconds, and the articulatory rehearsal process, which allows for the rehearsal of verbal information in order keep it in memory longer (Baddeley, 2003; Montgomery, 2003). This process is linked to literacy and numeracy and children with impairments are at a high risk for underachievement (Alloway, Gathercole & Elliot, 2010). Children rely on the phonological loop process for a number of tasks and deficits can lead to difficult with language acquisition, reading comprehension, following instructions, understanding sequences, speech difficulties, social difficulties (related to understanding facial expressions, who said what, interpreting tone) and following conversations. (Alloway, Gathercole & Elliot, 2010; Hood & Rankin, 2005; Rankin & Hood, 2005). In developing interventions for children with working memory disorders related to the phonological loop, it is important to first provide a behavioural definition (Upah & Tilly, 2002). Since memory is a cognitive process that cannot be directly observed, an operational definition,

WORKING MEMORY DISORDER INTERVENTIONS based on observable behaviours, is necessary. Such a definition needs to be objective, clear and complete as it provides the basis for the rest of the design, implementation and evaluation of the intervention (Upah & Tilly, 2002). For instance, if a childs memory disorder is related to the phonological loop component of working memory, one observable behaviour may be how well he (or she) can follow a list of verbal directions. The behavioural definition may include what the target behaviour is (following verbal directions) which may be defined by being able to listen to and act on said directions. The definition may further define examples of what would be acceptable actions, as well as define what would be unacceptable (Upah & Tilly, 2002).
The next step of the process is to measure the childs current level of functioning in the target behaviour, in this case the ability to follow a list of verbal directions (Upah & Tilly, 2002). This provides a baseline that will allow for evaluation and comparison throughout the course of the intervention. It is important that this data be collected in a way that is sustainable, as a consistent process will need to be used in order to yield comparable data (Upah & Tilly, 2002). When developing a data collection procedure, it is important to take into account how the data will be collected, who will collect it, when and where it will be collected and how often the behaviour will be measured (Upah & Tilly, 2002). It is also important that the process yields a large enough range of results that changes in behaviour can be noted and tracked (Upah & Tilly, 2002). In this example, the child in question may be able to reliably, without intervention, follow only two verbal directions at a time. Two would become the baseline measurement, and progress monitoring would track whether or not this improved over the course of the

intervention. The final stage of problem identification involves determining if the problem is serious enough to need intervention (Upah & Tilly, 2002). This is generally done through a comparison of the baseline data collected and what would be expected from a typically developing peer (Upah &
Tilly, 2002). If there is a difference in performance level, it is also important to determine if that

WORKING MEMORY DISORDER INTERVENTIONS difference is significant enough that intervention is necessary (Upah & Tilly, 2002). With the child whose baseline score for direction following was two, a comparison needs to be made in regards to other children at the same developmental level. If the childs peers, on average, scored much higher (such as an eight), this would indicate a significant discrepancy and intervention would be warranted. However, if the childs peers only scored a point or two higher on average, it may be the case that intervention is not needed at this time. In order to complete this aspect of the process, a thorough assessment of the childs abilities is required. In assessing memory abilities, it is important that a full work up be completed, including information regarding general intelligence, executive functioning and academic achievement (Hood & Rankin, 2005). It is important to determine the underlying cause for the noted behavioural concerns, in order to ensure that interventions are targeting the true concern, and not a surface concern (such as attention) that may be masking a different concern (such as memory) (Hood & Rankin, 2005). Assessment tasks specifically related to working memory include digit and word span tasks (forward and backwards), and non-word repetition tasks (Maehler & Schuchardt, 2011; Montgomery, 2003). There are assessment tools dedicated to the assessment of memory, such as the Childrens Memory Scale (Cohen, 1997), the Automated Working Memory Assessment (Alloway, Gathercole & Pickering, 2004) and the Working Memory Rating Scale (Alloway, Gathercole, Kirkwood & Elliott, 2008). There are also memory components included in more general assessment measures like the Wechsler Intelligence Scale for Children (Wechsler, 2004).
Problem Analysis

The next step in Upah & Tillys (2002) process is to analyze the problem based on the both known and unknown information. This includes developing a general hypothesis regarding why the problem is occurring and predicting how an intervention might change the behaviour

WORKING MEMORY DISORDER INTERVENTIONS (Upah & Tilly, 2002). The hypothesis is validated through design of the intervention and careful observation of its effect. An important part of this process is to ensure that the hypothesis is directly link to the childs specific assessment results (Upah & Tilly, 2002). A key factor of best practices is not simply proposing any intervention, but proposing the right intervention for the right child (Upah & Tilly, 2002). This is where a thorough understanding of different memory disorders, and their link to other deficits, is important. For instance, research has shown a strong connection between the phonological loop component of working memory and Specific Language Impairments (SLI) (Montgomery, 2003). Children with SLI have demonstrated reduced capacity to manipulate information, which is hypothesized to lead to difficulty with comprehension (Montgomery, 2003). These children may perform as well as their peers when it comes to their capacity to store information, but they have difficulty when they are required to process that information (Montgomery, 2003). The process can take longer for them, and they may be unable to process as many pieces of information at the same time (Montgomery, 2003). For a child with this profile, it will be important to develop a hypothesis that takes into account both the memory deficits and the SLI. Plan Implementation Prior to implementing an intervention, it is important to outline what the desired outcome is and to set appropriate goals (Upah & Tilly, 2002). This helps to ensure that the intervention will target the appropriate behaviour in an empirically supported way, and that there are standards in place for assessment and evaluation (Upah & Tilly, 2002). In goal setting, it is important to include a time frame for the intervention, a setting or condition for the intervention, a description of what the tasks involved are and the target level of behaviour that it is hoped the child achieves through the intervention (Upah & Tilly, 2002).

WORKING MEMORY DISORDER INTERVENTIONS There are a number of general intervention strategies related to deficits with phonological loop processing. Teachers may be asked to help the child to focus their attention on key information, to speak to the child clearly and slowly, to provide visual prompts to go with verbal information, to give the child time to process information, to present information in smaller chunks and to use existing knowledge as a foundation for new information (Gillam, 1997; Montgomery, 2003; Rankin & Hood, 2005; Smith, 2004). A child may be taught to organize information into meaningful chunks or categories, to summarize information by asking questions or drawing pictures, to practice recall strategies, to put information into their own words and to rehearse key information (Gillam, 1997; Montgomery, 2003; Rankin & Hood, 2005; Smith, 2004). Activities that support phonological coding such as reciting nursery rhymes, developing listening skills and using rhyming skills can also be effective (Gillam, 1997). Many children, including those with memory deficits, may over estimate their memory abilities, so it is important to teach them how to monitor their own learning and memory usage, and to explicitly teach specific strategies to use and when to use them (Barry, 2006; Smith, 2004). While the overall goal may be to improve memory function, setting a specific goal allows interventions to be developed which target specific concern behaviours. For instance, some children with phonological loop deficits experience difficulty with social development, as their memory disorder makes it hard for them to follow conversations, read facial expressions and understand tone of voice (Hood & Rankin, 2005). Rather than working with a very general memory intervention, the goal for a child with this type of concern may be to help the child to develop better social skills by practicing skills that have been hampered by their memory deficits. The goal may specify the number of opportunities a child be given to engage in conversations, and set out specific expectations related to those conversations, such as

WORKING MEMORY DISORDER INTERVENTIONS identifying facial expressions, asking for clarification of tone of voice and using cue cards to help guide conversation topics(Hood & Rankin, 2005). The next stage is to plan out the steps that will be taken to help the child to achieve the determined goal (Upah & Tilly, 2002). This needs to include the specific steps to be taken, who will take them, how often and when (Upah & Tilly, 2002). While there is copious amounts of information available regarding general intervention strategies for memory disorders, this is the stage that considers all of the preceding information specific to the child in determining the a specific plan of action. For instance, a general memory intervention for children with a phonological loop deficit is to ask them to mentally picture the information they have just heard (Smith, 2004). In developing the intervention plan, it is important to be much more specific. In this case, the plan may call for the teacher to teach the child a specific visual imagery strategy, such as RIDER: Read the sentence Imagine turn the sentence into a picture in your mind Describe talk about how this new picture is different from the last sentence Evaluate determine if your picture includes all the important details Repeat for the next sentence. (Smith, 2004)

The implementation plan may call for an initial lesson on the strategy, modeling and/or reminders of the process by the teacher or a peer (which tapers off as the child masters the process) and accountability for consistently applying the process. The plan may further describe which passages/subjects the child should use this process for and allow for extra time for the child to engage in the process. In order to follow track the progress of the intervention and ultimately evaluate it effectively, it is important that there is a plan in place to measure the childs performance (Upah & Tilly, 2002). A good measurement strategy will help to determine if the intervention is

WORKING MEMORY DISORDER INTERVENTIONS working and needs to include information on who will collect data and how it will be collected (Upah & Tilly, 2002). In the case of the child who is taught to employ the RIDER strategy, the measurement may be related to the number of oral, multiple choice questions out of ten he can correctly answer after reading a passage of text. This could be measured before the intervention begins (baseline), and then twice a week throughout the intervention period. The teacher (or other professional) would be able to track this progress to determine if the child is making progress in the reading comprehension. The final stage of plan implementation is determining an action plan around a decision rule (Upah & Tilly, 2002). This will allow teachers and others working with the child to make objective decisions about a childs progress, and to determine what the next step in the process should be, depending upon what results are achieved (Upah & Tilly, 2002). For instance, a decision rule for the above child may involve a level at which active intervention (modeling, reminding) ceases (such as 8 out of 10 correct on the comprehension quiz), or may require an increase in intensity or frequency of the intervention if a certain level of progress is not obtained within a given time period. Program Evaluation The final stage in Upah & Tillys (2002) process is to evaluate the program. The measurement strategy can be used to provide data to track the childs progress, which can in turn be used to determine if an intervention is working (generally based on the decision rule). This type of progress monitoring can also be used to conduct a formative evaluation, which helps to determine if changes should be made to the intervention, specifically if modifications can be made to increase the effectiveness of the program (Upah & Tilly, 2002). For instance, with the child learning the RIDER technique, it might be determined that this intervention has quickly

WORKING MEMORY DISORDER INTERVENTIONS helped the child to build up enough reading comprehension skills to accurately recognize the information needed to answer the multiple choice questions. A formative evaluation may determine that in order to increase the effectiveness of the intervention the child needs to be encouraged to use the strategy across more subject areas and/or work towards being able to recall, versus recognize, the information. Of course, any evaluation of the strategy needs to ensure the implementation plan was followed accurately (Upah & Tilly, 2002). This is important in order to understand why progress was or was not made, to make adjustments to the intervention and to develop follow-up interventions (Upah & Tilly, 2002). If the child was not consistently following the RIDER strategy, or if the teacher did not follow through with modeling the strategy, lack of progress may be related to poor implementation, rather than the manner of intervention. The final stage of Upah & Tillys (2002) twelve-step best practice process is to provide a summative evaluation of whether or not the intervention worked. This can be done through an analysis of the childs initial baseline performance and their performance after the intervention (Upah & Tilly, 2002). This evaluation can determine if the intervention was successful enough (i.e. the child has made sufficient progress) that further intervention is not necessary, or if a maintenance intervention is more appropriate (Upah & Tilly, 2002). If the child has not made sufficient progress, it may be time to either change the intervention or to reanalyze the problem. If the child using the RIDER technique is not showing any progress, this evaluation process can point to either the implementation of a different technique, the addition of new techniques to the process or even a need to re-assess the underlying deficits the child is struggling with.

WORKING MEMORY DISORDER INTERVENTIONS Designing, implementing and evaluating any intervention is a complex, time consuming process. It requires a good base of knowledge, a strong assessment background of the child in question, attention to multiple levels of detail, good follow-through and a significant amount of time. However, the benefits to the child are well worth the costs. For children struggling with memory disorders related to the phonological loop component of working memory, the deficits they face are multi-faceted and complex. They may face difficulties academically, cognitively and socially, and the gap between their abilities and their peers may widen with each passing year if they do not receive support, and may eventually require even more intensive intervention on additional levels in order to help the child to succeed. Timely interventions, based around best practices for design, implementation and evaluation, offer the child the best opportunity for success.

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