Evaluation of the Errorless Learning Technique in Children With Traumatic Brain Injury

Article Outline

• Abstract
• Errorless Learning in Adults
• Methods
  • Participants
  • Procedure
    • Measures of memory
  • Phase II: Comparison of Errorless and T&E Learning Techniques
  • Intervention Procedures
    • Materials
    • Training
    • Maintenance and transfer of learning
  • Statistical Analysis
• Results
  • Initial Learning (Trial 4)
  • Retention of Initial Learning at Different Intervals
    • Two-day retention interval
    • Seven-day retention interval
    • Twenty-one-day retention interval
    • Forty-nine-day retention interval
    • Seventy-seven-day retention interval
• Discussion
• Conclusions
• Acknowledgments
• APPENDIX 1. Sample declarative items
• References
• Copyright

Abstract 

Landis J, Hanten G, Levin HS, Li X, Ewing-Cobbs L, Duron J, High WM Jr. Evaluation of the errorless learning technique in children with traumatic brain injury.

Objective

To compare errorless learning with trial-and-error (T&E) learning of declarative facts in children with memory disorders secondary to traumatic brain injury (TBI).

Design

Retrospective within-subjects concurrent treatment design.

Setting

Participants’ school or home.

Participants

Thirty-four children, ages 6 to 18 years, with mild, moderate, or severe postacute TBI who met criteria for memory impairment.

Intervention

Conditions consisted of an errorless learning method and a T&E method. Within a session, half the items were taught with the errorless learning method and half with the T&E method. Each child received two 1-hour sessions a week for 7 weeks.

Main Outcome Measures

Relative effectiveness of errorless learning and T&E methods for (1) initial learning and (2) retention over time for learned items.

Results

There was an advantage for T&E on initial learning. In children with mild, but not moderate or severe TBI, 2-day retention was better with the errorless learning technique; 7-day retention was better with errorless learning in young children with mild TBI. Seventy-seven-day retention revealed an advantage for errorless learning in younger children with severe TBI.

Conclusions

Findings did not support errorless learning as a generalized intervention for learning difficulties after TBI or identify specific age- or injury-severity groups that benefited from this technique.

Key Words:  Brain injuries , Pediatrics , Rehabilitation

ERRORLESS LEARNING TECHNIQUES¹, ², ³, ⁴ purportedly enhance learning by eliminating interference from erroneous information during the learning phase as in trial-and-error (T&E) learning. The idea of increased susceptibility to interference effects associated with prefrontal injury has been invoked to explain the alleged benefit of using the errorless learning technique. Because of implications for rehabilitation, the errorless learning technique has generated considerable interest despite equivocal results in adults with brain injury.⁵ Surprisingly, among school-aged children for whom learning is central to daily experience, there have been very few studies of errorless learning and no reports of the efficacy of this technique in the remediation of learning difficulties that frequently result from traumatic brain injury (TBI) in children.⁶, ⁷

Although it is reported that most children who have sustained a TBI will recover intellectual functioning to within the normative range as measured by standard tests of intelligence,⁸ academic deficits frequently persist in children who sustain severe TBI.⁹, ¹⁰, ¹¹ Brain injury may result in the loss of previously learned academic skills, reducing the performance of a skill or compromising the child’s ability to attain a future developmental level.¹² The prevalence of episodic memory deficits after pediatric TBI has been well documented.⁸ Deficits in memory functioning can negatively affect academic achievement because of poor retention and retrieval of information.⁹, ¹³ Research findings have delineated specific neuropsychologic deficits impacting academic performance and resulting in special-education placement after TBI in children. For example, Kinsella et al¹⁴ found that neuropsychologic and academic measures at 3 and 24 months postinjury predicted a change in educational placement from regular to special education 2 years after TBI. Children who later required special-education services had impairments in verbal learning, memory, and slowing in speed of information processing, skills critical to long-term academic success in the classroom.¹⁵ The provision of appropriate educational services requires an understanding of changes in cognitive development after pediatric TBI, yet there are few studies of cognitive remediation of children after TBI.¹⁶, ¹⁷

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Errorless Learning in Adults 

Early studies of errorless learning techniques tended to focus on experimental tasks, such as word list recall, which are easy to evaluate but of limited practical value. More recently, naturalistic tasks have been used to assess the usefulness of errorless learning when applied to everyday activities, with mixed results. For example, although studies of patients with brain damage showed an advantage for the errorless technique in training for a memory device,¹⁸ later studies⁵ failed to show an advantage of errorless learning over a T&E method on face-name matching and free recall even with first-letter cueing. Such results have been hypothesized to support the assertion that errorless learning is most beneficial or even only beneficial under circumstances that facilitate the implicit retrieval of knowledge,¹⁹ rather than explicit retrieval of a target. The idea is that under these circumstances implicitly activated near-target “candidates” in one’s knowledge base may interfere with learning. Errorless learning would confer benefit by reducing the amount of interference encountered by limiting target options during the study stage. An alternative explanation of the errorless advantage is that it supports residual explicit memory. Many of the patients in studies of errorless learning were memory impaired but not completely amnesic; on this account, the residual explicit memory processes of the patients allow them to receive benefit from errorless learning in both cued recall and free recall (both of which are considered to rely on explicit memory processes) including tests of novel learning.¹⁸, ²⁰ Finally, the relative involvement of explicit and implicit memory processes in mediating errorless learning might vary across patients depending on the severity of their declarative memory disorder.²¹

By using a within-subjects design, Tailby and Haslam²¹ discovered that instructing memory-impaired patients to generate a target word to an elaborative description during “errorless” study improved performance on cued recall (when the cue was the first 2 letters of the word) as compared with a standard errorless technique without elaborative strategies. However, a condition evaluating the effect of generation and elaboration on the corresponding errorful condition was not included in this study; therefore, it is difficult to discriminate the relative benefits of the errorless part of the technique from the well-known effects of enhanced learning of both generated items²² and contextually relevant materials (levels of processing effects).²³

In sum, regardless of the mechanism hypothesized, the advantage of the errorless learning technique among patients with memory impairment is not universal but seems to vary according to a range of factors including type of test, stimulus materials, and length of retention interval. Among studies that have found a positive effect of errorless learning, a common finding is that patients with the most severe impairments in memory appear to be most likely to receive benefit from the errorless technique, suggesting that a closer characterization of the persons benefiting from errorless learning might provide insight for its efficacious use.

We compared the effectiveness of the errorless learning technique to the T&E method in children with memory disorders secondary to TBI on acquisition, maintenance, and long-term learning of declarative knowledge. Second, we investigated whether subgroups of children with TBI identified by age and injury severity (mild, moderate, severe) responded differentially to errorless learning relative to T&E techniques.

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Methods 

Participants 

Subjects in this study consisted of 34 children and adolescents, ages 6 to 18 years, who had sustained a mild, moderate, or severe TBI at least 1 year before their participation. The children were recruited from a cohort enrolled in an ongoing study of neurobehavioral outcome after pediatric TBI. Children from this cohort were obtained from the pediatric and neurosurgery services at Ben Taub General Hospital and Texas Children’s Hospital, Baylor College of Medicine, Houston, TX, and Hermann Children’s Hospital, University of Texas Medical School, Houston, TX. Selection criteria for inclusion in the larger ongoing study were (1) TBI because of an acceleration-deceleration injury or impact of a blunt object, (2) age 15 years of age or younger at the time of their injury, and (3) normal vision and hearing. Children who met criteria for the overall study were then screened for memory impairment (defined below), and those who met the criteria for memory impairment were enrolled in the intervention study. Parents or guardians provided informed consent for participation in the study and for the release of medical records to document the TBI. Parents were compensated $50 for their time and travel expenses for participation in each phase of the study. Table 1 provides demographic and injury characteristics of the children who qualified for the intervention study for the 3 injury severity groups (mild, moderate, or severe injury) as determined by the lowest postresuscitation Glasgow Coma Scale (GCS) score.

Table 1. Demographic and Injury Variables for Children With TBI Qualified for Memory Intervention Study

NOTE. Values are mean ± standard deviation (SD) or as indicated.

Procedure 

Neuropsychologic assessment, including evaluation of memory, took approximately 5 hours. Half of the assessment methods were standardized measures widely used by psychologists in evaluating children’s intellectual, memory, academic, and behavioral functioning; the remainder were verbal learning tasks that have been used in cognitive studies of adults and children. However, only measures relevant to the current study are described here.

The Children’s Auditory Verbal Learning Test–2 (CAVLT-2) was included as a measure of declarative memory. It is composed of 1 recognition and 2 free-recall memory word lists and yields measures of immediate memory span, level of learning, immediate recall, delayed recall, recognition accuracy, and total intrusions. The dot locations subtest of the Children’s Memory Scale (CMS)²⁴ served as a measure of procedural memory by examining memory for spatial location and spatial ordering. After 3 learning trials, the child was asked to place chips on a grid in the same locations as the dots appearing on a stimulus page. Scores obtained provided a measure of learning, immediate, and delayed recall. The adult or child version of the Rivermead Behavioral Memory Test (RBMT)²⁵ was administered, depending on the age of the participant. The RBMT contains 12 subtests that are analogs of everyday tasks and examined a wider range of memory skills. The Wechsler Abbreviated Scale of Intelligence (WASI) was also administered to obtain a reliable, brief measure of intelligence and as the criterion of comparison with which to establish specific memory impairment. The WASI consists of 4 subtests (vocabulary, similarities, block design, matrix reasoning) and provides verbal, performance, and full-scale intelligence quotient scores.

Phase II: Comparison of Errorless and T&E Learning Techniques 

Based on their performance on the standardized measures, 33 children met inclusion criteria for specific memory impairment and were invited to participate in the second phase of the study. Selection criteria for the intervention phase included a full-scale score on the WASI that was at least 1 standard deviation (SD) (15 points) higher than the standard score on at least 1 subtest of the 3 standardized measures of memory: the CAVLT (verbal memory), CMS dots (visual spatial), and the RBMT (functional memory). Sufficient attention and cooperation to complete the intervention from the children were also required. By standardized measure, 13 (39%) children qualified on the CMS, 21 (63%) on the CAVLT, and 25 (76%) on the RMBT. The mean scores on these assessments by injury group are shown in table 2. As is obvious from the percentage qualifying scores, several children met the criterion on more than 1 measure: of the 33 qualifying children, 18 qualified on 2 standardized measures, 4 met criteria for memory impairment on all 3 of the standardized measures, and 11 children reached criteria on 1 measure.

Table 2. Scores on Memory Scales by Injury Severity Group

NOTE. Values are mean ± SD.

Intervention Procedures 

We adapted the within-subjects concurrent treatment design used by Wilson et al¹⁸ in a study of adults with TBI. Each child received training in declarative knowledge under each of 2 treatment conditions. The treatment conditions consisted of an errorless learning method and a more standard T&E method. The errorless learning method eliminated the production of incorrect responses, whereas the T&E method emphasized guessing by the child, thus maximizing the chance of error production. This design used both learning techniques within each session for all study participants, allocating half of the items to be learned to the errorless learning and half of the items to the T&E method. Although the order of treatment condition (errorless learning, T&E) was consistent for each subject across sessions, the order of first presentation was counterbalanced by subject. Thus, half the subjects began each session with errorless learning, and the other half of the subjects began with T&E. This design minimized nonspecific effects of learning over time, thus decreasing variance not caused by the treatment condition.

Instruction was provided in two 1-hour individual sessions a week for 7 weeks. Three of the 7 weeks were spent on training in declarative knowledge consisting of science and social studies facts, followed by 3 weeks of training on unrelated procedural skills not reported here. After a week delay, children were assessed on retention of the 3 units of declarative knowledge (science and social studies facts) taught by each of the errorless learning and T&E methods.

Science and social studies facts represent an important domain of knowledge for academic achievement. In addition, they provided a well-circumscribed training domain for use in the current treatment interventions. Children were initially individually screened with a large number of developmentally appropriate science and social studies facts. From this screening, an individualized subset of facts unknown to the child was identified. From this subset, 3 units of instructional materials were then compiled for each child. Each unit contained 10 items for errorless learning instruction and 10 items for T&E instruction for use during each teaching session. The items consisted of sentences stating a science or social studies fact, with a key word left blank (appendix 1). Of the set of unknown science and social studies facts for each child, half were assigned to the errorless learning condition and half to the T&E condition. To ensure that learning within a treatment condition is not dependent on a specific order of item presentation, within each treatment condition (errorless learning, T&E) science and social studies facts were mixed and presented for study 10 times in a random order. Each of the 2 treatment conditions is briefly described.

In both treatment conditions (errorless learning, T&E), a continuous time delay procedure was used. Children were allowed 4 seconds in which to view the item to be learned together with the correct response (errorless learning) or to produce guesses (T&E) after which the experimenter repeated the item and the correct response. During the errorless learning instructional treatment, the intervention facilitated knowledge acquisition and retention by using a technique that eliminated guessing and thus the production of incorrect responses. Children were presented with the unknown science or social studies item and the correct response (eg, A plant-eating animal or insect is a [herbivore]). The child was told the correct response, repeated the correct answer after the instructor, and was told to remember that answer for later testing. Thus, the children were not given an opportunity to produce an incorrect response during the errorless learning trial.

During the T&E instructional treatment, the child was presented with the unknown science or social studies item (eg, A plant-eating animal or insect is a “______”) and asked to guess the correct response. No limit on the number of guesses within the 4-second delay was made. The child was encouraged to guess on the first presentation of the stimulus sentence. If the child did not provide the correct response, the trainer then responded, “That was a good guess, but the answer is ‘herbivore’.” If the child provided the correct response, the trainer then moved on to the next question. If the subject responded with the wrong answer, the trainer then corrected it. The child was asked to then repeat the item and the correct response, and then the trainer presented the next science or social studies item. In every trial, under both treatment conditions, the item and the answer were presented 3 times.

To assess maintenance of information learned over time, learning of science and social studies facts that comprised the 3 units of declarative knowledge on which the child had been trained was assessed. Assessment for retention occurred at the following time periods: immediately after instruction and 2 days, 1 week, 3 weeks, 7 weeks, and 11 weeks after the initial instructional session. Except for the initial session, the child began each treatment session by completing a cued-recall task (eg, A plant-eating animal or insect is a “______”) using the previous session’s trained science or social studies items. The number of correct items recalled was recorded. To assess progress during each day of training, children were tested on the trained science and social studies facts from that day at the end of each individual session. On completion of the final declarative knowledge treatment session at the end of 3 weeks, 4 weeks later, and at a 1-month follow-up session, maintenance of learning was again assessed by asking the child to complete a cued-recall task by using the same materials for all 3 units of information used during the training sessions. The number of correct items recalled for each unit and by treatment type was recorded for later data analysis.

We evaluated the relative effectiveness of errorless learning and T&E methods for 2 aspects of children’s learning. First, we evaluated the initial learning, which we estimated by the number of correct responses immediately after the study trials. Second, we evaluated the degree of retention over time for items that were learned. We estimated the percentage retained for each of the test intervals (2d, 7d, 21d, 49d, 77d) by dividing the number of correct responses at each interval by the number of items initially learned for each child.

Our measure of interest was the difference between the errorless learning method and the T&E method, so each analysis was conducted by using a difference score calculated by subtracting the T&E correct responses from the errorless learning correct responses.

Statistical Analysis 

Descriptive statistics were summarized by using analysis of variance and the Fisher exact test among the 3 severity groups. A general linear mixed model was used to see how the differences of these 2 methods changed over time among these severity groups by controlling other factors, such as age, age since injury, and so on. Because the retention intervals are unequally spaced, we used spatial power law covariance structure. There was a significant 3-way, severity by age by trial, interaction effect; therefore, we did separate analyses within each trial to see how age and severity affect the difference by using a general linear model. For each analysis, if preliminary analyses revealed that age was not a factor, it was dropped from the model. Statistical significance level was set at .05.

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Results 

Initial Learning (Trial 4) 

There was a significant difference between the methods on initial learning (t₃₃=−4.01, P=.000), in which T&E learning yielded more correct responses (mean, 7.1 items) than the errorless learning method (mean, 6.3 items). The initial difference in the errorless learning method and the T&E method was not related to age, severity (as determined by the GCS score), time since injury, or memory screening score, and there were no interactions.

Retention of Initial Learning at Different Intervals 

To look at the difference in retention between the errorless learning and T&E methods, we calculated the percentage of items initially learned that were retained at each interval (retention interval: 2d, 7d, 21d, 49d, 77d). We then performed analyses on the difference score between the 2 methods (difference score = percentage of correct errorless learning − percentage of correct T&E). Table 3 shows the mean number of items learned for each condition and the percentage retained at each interval by condition.

Table 3. Scores of the Initial Learning Assessment and Subsequent Tests by Interval

NOTE. Values are mean ± SD.

The overall analysis of the retention interval indicated that there was a main effect of injury severity on the difference score (F_2,27=7.73, P=.002) but no main effect of age (F_1,27=2.35, P=.137). Injury severity interacted with retention interval (F_8,105=2.96, P=.005) and age (F_4,105=5.72, P=.009), and there was a 3-way interaction of injury severity, age, and retention interval on the difference score (F_8,105=2.16, P=.037).

To further explore these effects, we analyzed each retention interval separately for the effects of age and severity on the difference score for each retention interval.

Injury severity significantly affected the difference score (F_2,30=4.95, P=.014) such that children with mild injuries showed a greater difference in methods (with an advantage for errorless learning) than did children with either severe or moderate injuries. There was no effect of age, and severity did not interact with age on the difference score.

Injury severity significantly affected the difference score (F_2,27=5.85, P=.008) such that, overall, children with mild injuries showed a greater difference in methods than did children with either severe or moderate injuries. However, this effect was modified by age (F_2,27=3.88, P=.033), such that injury severity was a factor in the difference score only for younger children, with younger children with moderate TBI showing a greater advantage for T&E than older children at this time point. Children with mild and severe injuries showed the opposite pattern, an advantage for errorless learning at younger ages, decreasing with age, although this pattern was not significant. The complexity of this interaction is shown in figure 1.

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• Fig 1. 

  Difference in methods by age and severity at 7-day retention interval. Difference is expressed as errorless learning minus T&E; therefore, positive values indicate advantage of errorless learning method and negative values indicate advantage of T&E method.

There were no significant effects of either injury severity or age on the difference in methods at this retention interval.

There were no significant effects of either injury severity or age on the difference in methods at this retention interval.

As with the 7-day interval, the difference because of injury severity depended on age (F_2,25=3.79, P=.036); injury severity was a factor in the difference score only for younger children; however, in contrast to the 7-day interval, here the children with severe injuries showed a greater difference in methods, with an advantage of the errorless learning method at an early age than did either the milds or moderates.

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Discussion 

Declarative memory deficit is a frequent sequela of TBI in children, contributing to poor academic achievement in later years.⁷, ²⁶ However, controlled studies of techniques to facilitate learning in this population are sparse. Errorless learning has received support in some, but not all, studies of adults and children with learning problems associated with congenital conditions and in adults with acquired neurologic disorders and brain injury.², ⁵, ¹⁸, ²⁰, ²¹, ²⁷ To our knowledge, this is the first study to compare errorless learning with a T&E technique in children with memory deficit arising from TBI. To facilitate extrapolation of our findings to clinical and educational settings that assess and remediate children with memory problems after TBI, we selected children with TBI who showed a disproportionate memory deficit relative to their intellectual function. To simulate classroom demands on learning, the instructional materials were based on science and social studies curricula. Following the within-subject study design used to compare errorless with T&E learning techniques in adults,⁵ children were exposed to both learning methods within each intervention session. We elected to use this within-subject approach because of difficulty in matching groups of children on severity of memory deficit and the larger sample needed for a randomized, between-groups design. Although we designed the training in each session to present material in different subject areas by using the errorless and T&E techniques, we recognize that this approach was less robust to crossover effects than a between-groups design. In addition to evaluating initial learning, we compared retention of material at various intervals after initial learning with the errorless and T&E technique (fig 2).

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• Fig 2. 

  Difference in methods by severity of injury and retention interval. Difference is expressed as errorless learning minus T&E; therefore, positive values indicate advantage of errorless learning method and negative values indicate advantage of T&E method.

Initial learning was more efficient when using the T&E method than the errorless technique. However, in children with mild, but not moderate or severe TBI, retention at 2 days after the initial learning was better for material taught when using the errorless technique. At 7 days after initial learning, a similar advantage of errorless learning was found for children with mild TBI, but this effect was specific to younger children. Further, children with moderate TBI showed a different pattern than children with mild or with severe TBI. Retention at the longest retention interval of 77 days postinitial learning also revealed an advantage for errorless learning, but this effect was specific to young children who had sustained severe TBI. The explanation for these dissociations in efficacy of the 2 techniques in initial learning in contrast to long-term retention is not apparent. If errorless learning reduces interference from processing erroneous information, then the effect on initial learning might be predicted to be similar to that of long-term retention. It is also unclear why the enhanced retention over the first week after training with errorless learning was limited to children with mild TBI, whereas statistically improved retention after more than 2 months was specific to children who had sustained severe TBI and were younger. However, it might be postulated that subtle distinctions in the neural mechanisms mediating initial learning and delayed retention may be contributory to the observed dissociation in effects for errorless and T&E techniques. Initial learning is supported by the hippocampus,²⁸ whereas retrieval of material over longer intervals after initial learning is thought to be increasingly mediated by the prefrontal cortex,²⁹ which is highly vulnerable to focal lesions that occur more frequently with severe TBI than with mild TBI.³⁰ If prefrontal injury increases vulnerability to interference, then any advantage accrued by training with errorless learning may be more salient at longer retention intervals, which introduce additional interference from intervening events and activities after the initial learning. The enhancement of initial learning by using the T&E technique was not specific to children with a particular level of brain injury severity. Moreover, it is plausible that this initial advantage of the T&E method might be a general finding in school-aged children with relatively poor memory efficiency rather than a result of TBI. Consistent with this postulation, Di Stefano et al³¹ found that prefrontal lesion volume was related to a declarative memory deficit on the CVLT in children with TBI, whereas these investigators found only a marginal effect of hippocampal volume on memory. With words belonging to 3 semantic categories, retrieval on the CVLT is facilitated by semantic organization of the items, a strategy that recruits the prefrontal cortex. We acknowledge that this postulation is speculative given the lack of brain imaging data for our subjects. However, future studies performed by using functional brain imaging and revised procedures for testing learning and retention could investigate the relative contributions of the prefrontal cortex and hippocampus to initial learning and long-term retention.

Limitations of this study include unblinded examiners for evaluating retention of the material after the initial learning and the small number of participants, which precluded investigating age-related effects such as age at injury and time since injury. Further, a larger study would allow for investigation of the types of memory impairment, as revealed by specific subtests, that may benefit differently from these 2 methods of intervention.

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Conclusions 

Our findings do not offer support for the use of the errorless learning method as a generalized intervention for learning and memory difficulties in children acquired as a result of traumatic brain injury nor do they identify specific age or injury severity groups that might benefit from this technique. Further studies with larger numbers of patients are required to determine whether other variables, such as age at injury or interval since injury, are important to the efficacy of the errorless technique in this population.

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Acknowledgments 

We are indebted to Irina Zilberfayn, MA, for assistance in data collection and management during the research project and to Stacey K. Martin for her assistance in manuscript preparation.

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APPENDIX 1. Sample declarative items 

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