Practitioner-Oriented Principle (POP)
for a Cognitively Impaired Audience:
Persons with Schizophrenia
ED TEC 640 -- Psychology of Technology-Based Learning
Introduction
POP
Research on Possible Audiences
Mentally Ill
Bipolar (Manic Depressive)
Schizophrenia
Brain Damaged
Alcohol-induced
Strokes
Aphasia
Multiple Sclerosis (MS)
Summary of Findings
Narrowing Scope to One Audience
Determining Audience’s Strengths and Weaknesses
Weaknesses
Strengths
Narrowing Strengths and Weaknesses Down
Weaknesses
Strengths
Determining a Research-based Design for the Strengths and Weaknesses
Research
Concrete Information
Chunking
Memory Aids
Memory Models
Emotion and Memory
New Scientific Findings about Memory
Cognitive Impairments
Technology and the Impaired
Design Model
Constraints
Enablers
Methods
Strategy
Tactics
Outcomes
Scope the Design Down
Developing Examples to Support the Design
References
This paper develops a practitioner-oriented principle (POP) for a cognitively impaired audience, based on:
research of different possible audiences
narrowing scope to one audience
determination of audience’s strengths and weaknesses
narrowing down these strengths and weaknesses
determining a research-based design for the strengths and weaknesses,
scoping the design down, and
developing examples to support the design.
The POP appears first. Then there are details about the steps listed above that helped to create the POP.
When the target audience has the cognitive impairment of schizophrenia, then instructional design should include concrete, nonverbal material, including photographs and line art, to compensate for their memory weaknesses. The design should use interactive multimedia for the presentation of the material. The design should include oral story-telling by the learners to support their memory strengths.
Research on Possible Audiences
The researcher wanted to explore different areas of persons who fit the term "cognitively impaired" in order to select one final target group. Several illnesses or conditions come under the term "cognitive impairment." General categories include mentally ill, brain damaged, and multiple sclerosis (MS). These different categories may be totally different, or they may have overlap in the cognitive impairments that they have. At the end of this section, a chart presents the similarities and differences.
Persons with depression have large memory losses when having electroshock therapy (ECT) (National Institutes of Health, 1985). The researcher had spoken several times with a young woman at a psychiatric hospital. One day she said, "I can’t remember you. I just had ECT." She knew that she was going to lose her memory.
There are possible causes of schizophrenia that affect the brain (Barlow & Durand, 1995, p. 594). There are neurotransmitter imbalances involving the brain chemicals dopamine and serotonin (p. 578). In some cases there is structural damage to the brain caused by viral infection (pp. 582-583). The descriptions of the neurotransmitter imbalances and viral infection do not indicate that these affect memory.
Fausto-Sterling (1994) tested adolescent schizophrenics. The only findings of significant differences in cognitive deficits were in short-term memory and long-term memory, with the schizophrenics scoring lower than the controls. Powers (1996) reported on a study of memory and schizotypes, persons with a liability for schizophrenia, but who did not necessarily have it. The study showed observable deficits in spatial working memory that fit with other research that shows their difficulty in similar memory tasks. The difficulties appeared to be related to functioning of the dorsolateral prefrontal cortex, which other research shows to be impaired in schizophrenia.
The researcher searched the World Wide Web for "brain damaged," and found information on alcohol-induced, aphasia, and stroke. Several listings were for jokes about "brain damaged," such as take this quiz and find out if you are brain damaged. This is a serious condition that affects the most important organ in the human body.
At the suggestion of Dr. Allen, the researcher contacted Michelle Warn at SDSU’s Interwork Institute that does research on the cognitively impaired and has developed computer rehabilitation regimes. She was going to have their staff send information on their research on learning principles and the cognitively impaired and on courses that they have developed. Unfortunately, none was received in time to include in this paper.
The National Institute on Alcohol Abuse and Alcoholism (1995) says that long-term alcoholism can lead to brain damage and cognitive defects with up to 75% of detoxed long-term alcohol-dependent patients having cognitive defects. Chronic alcohol use reduces long-term potentiation, that is possibly a mechanism used in learning and memory formation. Studies have shown shrinkage of the brain, especially the white matter. Alcohol damages several areas of the brain, especially the hippocampus and cerebellum. The damage observed includes a reduction in the number of dendritic branches and spines and a loss of neurons.
The Brain Facts article (Anonymous, 1997, p. 15) describes long-term potentiation (LTP) mentioned above as a "long-lasting increase in the strength of a synaptic response."
Washington University in St. Louis (1996) reported that strokes are the third largest cause of death in the U.S., killing 150,000 of the 500,000 new victims each year. Also, strokes are the largest source of disability, lingering on for 2 to 3 million people. Because there are no drugs, damage to even small areas of the brain increases, and victims lose crucial areas of the brain. Strokes impair the ability to walk, speak, see, and remember.
According to the National Aphasia Association (1997), aphasia, loss of ability with the spoken and written word, has 80,000 new victims a year, with a total of one million victims. The organization’s review of use of computers for teaching seems generally negative (Bluestone & Lefkowitz, 1997). One program did not use known theory, but just had a random use of words.
The most frequently reported intellectual problem of people with MS is problems with memory (National MS Society, 1997).
Johnson (1997) reported on new software available for students with multiple sclerosis (MS) and other illnesses to use the World Wide Web. For the dexterity impairment of MS, she said that the pwWebSpeak software can allow a disabled person to scan the web headings and links like a sighted person. The software is an improvement on programs that read the screen aloud, operating without a costly speech synthesizer and using low-cost or free software. However, she did not explain how this applies to cognitive impairments of MS.
Table 1 shows the researcher’s findings of cognitive impairment for each type of illness.
Memory |
Word |
Learning in General |
||
| Mental Illness | ||||
| Bipolar | X |
|||
| Schizophrenia | X |
|||
| Brain Damaged | ||||
| Alcohol-induced | X |
X |
||
| Stroke | X |
|||
| Aphasia | X |
|||
| MS | X |
|||
Table 1. Chart of cognitive impairments for each type of illness.
Five of the six groups researched have memory problems: bipolar, schizophrenia, alcohol-induced brain damage, stroke, and MS.
Narrowing Scope to One Audience
The researcher decided to narrow down the target audience of the cognitively impaired to one group, persons with schizophrenia. The reason for his choice was that several illnesses had memory problems and he felt comfortable staying with his usual target audience of the mentally ill. He decided to select memory problems as the weakness to be covered in the POP because memory was the most frequent problem found in the above literature search..
Determining Audience’s Strengths and Weaknesses
The planned POP will compensate for the audience’s weaknesses and provide for its strengths.
Research cited above indicates that schizophrenics have memory problems (Fausto-Sterling, 1994; Powers, 1996). Schizophrenia can include the characteristics and symptoms of hallucinations, delusions, and disorders of speech, emotion, and socialization (Barlow & Durand, 1995, p. 553 ). The researcher thinks that the delusions possibly can interfere with memory when the person cannot sort out reality from the delusion, not remembering what is real and what is delusional. The emotional disorders can interfere with the cognitive memory processing.
The researcher has observed schizophrenics in board and care residences who had extremely good memories, and could tell long detailed stories, or write out long detailed stories (Elliot, 1990; 1993). Whether they were delusional at the time is not the issue, but what is important is the fact that the memory was strong for ideas originating in their own head. They could repeat long strings of ideas on different occasions. The researcher interviewed a schizophrenic who believed that he could run 700 miles an hour and stop 747’s. He was delusional but often brilliant in the way that he expressed himself.
The researcher has observed that persons with schizophrenia do participate in learning situations in their day treatment on in-patient groups. The researcher has not seen any research on how well they do.
Narrowing Strengths and Weaknesses Down
Schizophrenics might have memory problems because of their delusional disorders and their emotional disorders.
Problems with schizophrenia and the brain do not involve the memory areas of the brain.
Schizophrenics might have cognitive strengths involving good memories.
Determining a Research-based Design for the Strengths and Weaknesses
The purpose of this section is to develop a descriptive design model based on research on memory and the cognitive impairment of schizophrenia. First is the research, and then the design model.
Research on memory includes the topics of concrete information, chunking, memory aids, memory models, emotion and memory, and new scientific findings about memory. Research on the disabled includes cognitive impairments and technology.
According to Hannafin & Hooper (1993), memory is greater for concrete information:
"3.1. Concrete information is more easily depicted, more imagable by learners, better remembered, and more consistently interpreted than abstract information (p. 205)."
Research by Paivio, Yuille, and Madigan (1968) supported the concreteness and imagability statement, with a conclusion that the two had a strong correlation, as one went up the other went up and vice versa.
According to Winn (1993), memory is greater for chunked or clustered information:
"2.6a. Information is processed and remembered in ‘chunks’ that are organized hierarchically."
Per Winn & Snyder (1996), behavioral psychology says that memory is only the learning of stimulus and response associations that practice can improve. They add additional mechanisms: chunking, interactive mental imagery, and meaning. We pack items to be remembered into a chunk in short-term memory that has a capacity of about 7 items (Miller, 1956). To recall, we "unpack" and retrieve the items. Chunking can be more effective if the items have something in common or form a spatial or temporal group.
Per Moore, Burton, & Myers (1996), the short-term memory can hold about 7 chunks of information (Miller, 1956). STM is a "work space" where the individual can use information for rehearsal, elaboration, decision-making, or it can be lost, or stored in long-term memory (Klatzky, 1980). There is research-basis for the very small capacity and short time period of working memory. Simon (1974, in Kozma, 1991, p. 193) concluded that the capacity of short-term memory is 5 to 7 chunks, and that it takes 5 to 10 seconds to fixate each chunk into long-term memory. So memory is fleeting.
Kozma (1991, pp. 196-7) says that research demonstrates that experts in a field organize their knowledge into meaningful chunks or schemata, but that novices may only have knowledge that is a set of fragments or phenomenological primitives. Schemata are organized structures existing in memory that involve abstractions, linked concepts, are dynamic, and provide a context for holding and interpreting knowledge (Winn & Snyder, 1996, p. 117).
Shiffrin & Schneider (1977, in Winn & Snyder, 1996, p. 127) found that the element of rehearsal (overlearning) leads to automatizing learned discrete items into a chunk, overcoming the limitations of working memory. They recommended that chunking be incorporated into media design as appropriate. Too much overlearning would create boredom.
The POSIT database (Allen & Eckols, 1997) states: "POSIT 1.1.2 Reduce users’ memory load by providing memory aids." This principle listed 8 tools or devices for using the computer to reduce the users’ memory burden, including electronic bookmarks, recent document, lists of codes and choices, and balloon helps.
The researcher’s comments (Elliot, 1997a) were that he generally agreed that these items listed can be useful. However, in his research and work with new users who are mentally ill or have MS, the explanation of how and why to use these items can be a burden on the working memory of his audience.
Anglin, Towers, & Levie (1996) discuss three memory models to explain the superiority of memory for pictures over words: the dual-code model, the single-code model, and the sensory-semantic model. One item of relevance (explain) is that the nonverbal system in dual-coding theory "includes memory for all nonverbal phenomenon, including such things as emotional reactions. (Rieber, 1994).
UCI researchers found that stress has a positive effect on memory, that people tend to remember better when having stress hormones during a memory task (Marquis, 1994). Researchers gave experimental subjects no beta blockers that reduced stress and told them emotional stories while giving them information to remember. The study confirmed the animal model in human terms. According to UCSD Neuroscientist Dr. Larry Squire:
"We never really knew what we were studying when we gave a foot shock to a rat. Now we have this contact point with humans. It really encourages the whole research enterprise in how the brain stores and retrieves memories."
Lang, Dhillon, & Dong (1995).studied the effects of emotion on memory in TV. They said that most studies had found that emotion was remembered better than no emotion. They created a "dimensional emotional theory" to describe various processes involved.
Lemonick, Nash, Park, & Willwerth (1995) say that memories of concrete facts and events and emotions go through the hippocampus and memories of fear are in the amygdala.
The Discovery Channel (Cowling, 1994) said that the hippocampus where memory goes is part of the limbic system where emotions go.
New Scientific Findings about Memory
The Discovery Channel (Cowling, 1994) reported that a man named Jeremy had a blood vessel burst and he lost his short-term memory. He and others led scientists to believe that the brain stores information in different places.
(Geary, 1997) reports that scientists now believe that there is no one center for memory in the brain, but that memory spreads all over. Dr. Steven Rose of the Open University says, "Memory resides simultaneously everywhere and nowhere in the brain." New details about how memory works include glutamate, adhesion molecules, protein messengers, synaptic tags, and convergence zones.
Lemonick, Nash, Park, & Willwerth (1995) reported that perceptions involve tens of thousands of firings of different sensory patterns. The combination of all these patterns, says UCSD Professor of Psychiatry Larry Squire,
"gives you a complete perception. The persistence of the firing patterns over time gives you the transformation from perception to memory of that object."
The storing together of many overlapping patterns can lead to a large memory coming together such as Proust’s taste of a cookie bringing childhood memories back, inspiring him to write Remembrance of Things Past.
The POSIT database (Allen & Eckols, 1997) has a listing, "POSIT 7.1.2 Provide access for users with cognitive impairments." In responding to it (Elliot, 1997b), the researcher pointed out that many mentally ill have "can achieve intellectual success despite having a psychiatric diagnosis. For these and others, he does not think they need a principle that says that they should avoid multimodal stimulation. They thrive on it." Further, he said,
"Schizophrenics have thought disorders. They have too many thoughts stuck in their heads. When they spout them out as "word salad," they seem stupid, but if you listen carefully, they must have some kind of cognition going on to be able to carry all of those thoughts."
Although he disagreed with the suggested access for cognitively impaired as applied to the mentally ill, this POSIT listing inspired the present paper because he wants to find a method that works with them.
The National Council on Disability (1996, p. 108) says that the development of the "information superhighway" "holds great promise for people with disabilities. All of these technological developments have the potential to . . . enhance educational opportunities."
This is a descriptive model. The conditions/constraints/enablers are an independent variable. The methods/strategies/tactics are an independent variable. The outcome is a dependent variable. Citations are for research described earlier.
Schizophrenics might have memory problems because of their emotional disorders (Barlow & Durand, 1995; Fausto-Sterling, 1994; Powers, 1996).
Positive emotional situations might minimize or eliminate temporarily the emotional disorders and memory problems (Rieber, 1994). Concrete materials (Hannafin & Hooper, 1993) and chunking into short-term memory and long-term memory will help memory (Winn, 1993). Oral story-telling opportunities can capitalize on their strengths and help memory learning (Elliot, 1990, 1993, 1997).
Nonverbal materials (Anglin, Towers, & Levie, 1996) that provide stimuli for positive emotional situations might compensate for the constraints of emotional disorders and memory problems (Rieber, 1994). Concrete items and pre-chunking can help memory. Redundancy and reinforcement could strengthen memorization.
Per nonverbal memory model, use nonverbal materials for teaching memory skills to schizophrenic students.
Use photographs and line art to present instructional material for memory skills for schizophrenic students. Use interactive multimedia and possibly use the web with hyperlinked graphics. Use story-telling by learners.
Memory scores will increase.
This step is for simplifying the design. On further reflection, the researcher still agrees that the design should have concrete nonverbal items and story-telling to help memory. He no longer feels that pre-chunking is necessary because he feels that the learner should do all of the chunking. By this he means that the material will not be overtly chunked or not chunked, but will just have an average amount of chunking, as if chunking had not been heard of.
He will use interactive multimedia for the presentation of material, but will not use the web at this point until doing further research and development using multimedia.
The final design is in the beginning of this paper.
Developing Examples to Support the Design
In reflecting on 3 previous projects that the researcher produced for the mentally ill, he realizes that he did not analyze the needs of the audience based on research, but on assumptions of his own, his professors, and fellow students working on the project. He did not break down the audience into subgroups such as bipolar and schizophrenic. The 2 multimedia presentations were largely verbal, and the instructor-led presentation on the Internet was mostly graphical but with a lot of verbal content. Having analyzed these briefly, he then developed an example from scratch to fit the current design.
An example to support the POP design is as follows. A schizophrenic target audience has a learning task to remember current events. The design includes the use of the following:
concrete, easily-recognized photographs of the faces of local, state, national, and international leaders
concrete, easily-recognized line drawings of the map of their city, state, or country, and of items that are emblematic of their area, e.g., movie camera for Los Angeles
Macromedia Director to present the material in interactive multimedia format with graphical links between the different topics
minimum of verbal material, either textual or audio
story-telling opportunity by the clients to explain what they remember
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