AJSLP Research Note Analysis of Story Recall in Military Veterans With and Without Mild Traumatic Brain Injury: Preliminary Results Karen Gallaghera and Tamiko Azumaa Purpose: The purpose of this study was to determine whether detailed analysis of story recall performance reveals significant differences between veterans with and without history of mild traumatic brain injury (mTBI). Method: Twenty-one military veterans participated, with 7 reporting history of mTBI. All participants were administered the Logical Memory I and II subtests from the Wechsler Memory Scale–Fourth Edition (Wechsler, 2009). Responses were scored for total correct ideas (TCI) and total words produced (TWP). Results: Although the groups did not differ in scaled scores, other measures did reveal significant differences. After a delay, the mTBI group showed a greater drop in TCI relative to the control group. Additionally, the control group showed an increase in TWP when the recall was delayed versus immediate; a pattern not observed for the mTBI group. Conclusions: The mTBI and control groups did not significantly differ in scaled scores. However, group differences were observed in TCI and TWP. The findings suggest that, relative to the control group, the mTBI group were less successful in retrieving episodic information and eliciting self-cueing. Small sample size limited data interpretation, and larger sample sizes are needed to confirm the findings. The results indicate that veterans with mTBI may present with symptoms persisting beyond the acute state of the injury. M ilitary veterans comprise a subgroup of individ- uals with a high incidence of traumatic brain injury (TBI) complicated by factors either not seen, or seen at significantly lower rates, in the civilian population. In veterans, the largest proportion of brain injuries are classified as mild (mild traumatic brain injury [mTBI]; MacGregor, Morrison, Quinn, & Garlarneau, 2011; Terrio et al., 2009). Recently, there has been increased attention focused on mTBI and possible long-term conse- quences. Researchers have studied subpopulations of individ- uals at higher risk for brain injury, including professional athletes, child/adolescent athletes (e.g., Covassin, Moran, & Wilhelm, 2013; Strain et al., 2015; Tapper, Gonzalez, Roy, & Niechwiej-Szwedo, 2017), and military service members (e.g., Nelson et al., 2010; Rigg & Mooney, 2011; Terrio et al., 2009; Verfaellie, Lafleche, Spiro, & Bousquet, 2014). Given the diverse nature of these higher risk groups, it can be assumed that there will be differences in the situational aspects surrounding the injury, the associated symptoms, and concomitant conditions. Thus, individuals may receive the same diagnosis, but appropriate assessment and treat- ment can differ across groups. Military veterans, in particu- lar, require additional consideration in the assessment of mTBI because of military culture issues that can influence the time frame of injury diagnosis (.

1. AJSLP
Research Note
Analysis of Story Recall in Military Veterans
With and Without Mild Traumatic
Brain Injury: Preliminary Results
Karen Gallaghera and Tamiko Azumaa
Purpose: The purpose of this study was to determine
whether detailed analysis of story recall performance reveals
significant differences between veterans with and without
history of mild traumatic brain injury (mTBI).
Method: Twenty-one military veterans participated, with
7 reporting history of mTBI. All participants were administered
the Logical Memory I and II subtests from the Wechsler
Memory Scale–Fourth Edition (Wechsler, 2009). Responses
were scored for total correct ideas (TCI) and total words
produced (TWP).
Results: Although the groups did not differ in scaled scores,
other measures did reveal significant differences. After a
delay, the mTBI group showed a greater drop in TCI relative
to the control group. Additionally, the control group showed
an increase in TWP when the recall was delayed versus
immediate; a pattern not observed for the mTBI group.
Conclusions: The mTBI and control groups did not
significantly differ in scaled scores. However, group
differences were observed in TCI and TWP. The findings
suggest that, relative to the control group, the mTBI
group were less successful in retrieving episodic information

2. and eliciting self-cueing. Small sample size limited data
interpretation, and larger sample sizes are needed to
confirm the findings. The results indicate that veterans with
mTBI may present with symptoms persisting beyond the
acute state of the injury.
M
ilitary veterans comprise a subgroup of individ-
uals with a high incidence of traumatic brain
injury (TBI) complicated by factors either not
seen, or seen at significantly lower rates, in the civilian
population. In veterans, the largest proportion of brain
injuries are classified as mild (mild traumatic brain injury
[mTBI]; MacGregor, Morrison, Quinn, & Garlarneau,
2011; Terrio et al., 2009). Recently, there has been increased
attention focused on mTBI and possible long-term conse-
quences. Researchers have studied subpopulations of individ-
uals at higher risk for brain injury, including professional
athletes, child/adolescent athletes (e.g., Covassin, Moran,
& Wilhelm, 2013; Strain et al., 2015; Tapper, Gonzalez, Roy,
& Niechwiej-Szwedo, 2017), and military service members
(e.g., Nelson et al., 2010; Rigg & Mooney, 2011; Terrio
et al., 2009; Verfaellie, Lafleche, Spiro, & Bousquet, 2014).
Given the diverse nature of these higher risk groups, it can
be assumed that there will be differences in the situational
aspects surrounding the injury, the associated symptoms,
and concomitant conditions. Thus, individuals may receive
the same diagnosis, but appropriate assessment and treat-
ment can differ across groups. Military veterans, in particu-
lar, require additional consideration in the assessment of
mTBI because of military culture issues that can influence
the time frame of injury diagnosis (Rigg & Mooney, 2011).
Additionally, service members and veterans with a history
of mTBI are more likely than civilians to report unremitting

3. cognitive symptoms. Approximately 5% to 20% of athletes
with mTBI reportedly present with long-term symptoms
of mTBI (Jotwani & Harmon, 2010) compared with 7.5%
to 40% of veterans reporting chronic postconcussive symp-
toms (Cooper et al., 2015). These differences contribute
to the complexity of diagnosis and subsequent treatment
planning for mTBI-related symptoms in veterans.
Service-Related Factors in Assessment
and Treatment
Service-related factors can further complicate assess-
ment of longer term cognitive deficits related to mTBI.
For example, although delayed reporting of mTBI occurs
aDepartment of Speech and Hearing Science, Arizona State
University, Tempe
Correspondence to Karen Gallagher: [email protected]
Editor: Margaret Blake
Associate Editor: Carl Coelho
Received October 31, 2016
Revision received March 22, 2017
Accepted November 21, 2017
https://doi.org/10.1044/2017_AJSLP-16-0208
Publisher Note: This article is part of the Special Issue: Select
Papers
From the 46th Clinical Aphasiology Conference.
Disclosure: The authors have declared that no competing
interests existed at the time
of publication.
American Journal of Speech-Language Pathology • Vol. 27 •
485–494 • March 2018 • Copyright © 2018 American Speech-

4. Language-Hearing Association 485
https://doi.org/10.1044/2017_AJSLP-16-0208
in civilian settings (Hoffer, 2015), delayed or lack of injury
report is much more likely to occur for veterans/service
members, especially in combat settings (Defense and Vet-
erans Brain Injury Center, 2016). Veterans may be more
inclined to delay or avoid diagnosis due to military culture
issues, including the context of active combat situations,
lack of observable injury, and the belief that seeking health
care is a sign of weakness (Hyatt, Davis, & Barroso, 2014).
This perception of weakness is particularly prevalent when
the symptoms are not physically visible and may be per-
ceived as mental health related (Cooper et al., 2015; Hoge
et al., 2008). Additionally, military administrative factors
can cause hesitation in the reporting of mTBI symptoms.
With a reported injury, military protocols related to assess-
ment and treatment could delay the stateside return date
of the deployed service member, disrupt or cause failure in
training, or potentially delay exiting service at the end of
an enlistment (Rigg & Mooney, 2011).
Despite the incidence of unremitting symptoms in
veterans, some researchers conclude that there are no long-
term neuropsychological deficits associated with service-
related mTBI (e.g., Hartikainen et al., 2010; Jak et al., 2015).
Long-term symptom complaints have been attributed to
posttraumatic stress disorder (PTSD) or other variables,
such as reduced effort or mental health issues (Lange et al.,
2012; Nelson et al., 2010; Verfaellie et al., 2014). Kontos
et al. (2015) concluded that history of mTBI secondary to
blast injury (common in combat environments) can impact
cognitive functions, but the study participants were only
followed for 20 days postinjury. Despite ongoing research,

5. the issue of long-term neuropsychological consequences of
mTBI in military veterans remains equivocal.
In veterans with mTBI, there are also complicating
factors related to the service environments, specific assess-
ments, and the transition from military to civilian life. Vet-
erans may only become aware of subtle cognitive deficits
arising from mTBI after they exit the highly structured
environment of the military and transition to college or the
civilian workforce (DiRamio et al., 2008). This transition
can be intense, affecting all facets of life, such as social
interactions, personal relationships, and vocational demands.
It requires new learning and may exert increased cognitive
demands resulting in a more pronounced presentation of
subtle symptoms. Given the subtle nature of these deficits
and their exacerbation in complex, high-demand environ-
ments, existing standardized assessment protocols may lack
the ecological validity to quantify memory deficits associ-
ated with mTBI in any population.
Limitations in Traditional Neuropsychological
Assessment of mTBI
Standard neuropsychological tests often assess mem-
ory with simple tasks, such as digit span or word recall.
Simple verbal memory tasks that involve rote memory lack
ecological value and are often not sensitive to subtle mem-
ory impairments arising from mTBI (e.g., Geary et al.,
2011). Digit span, including digits forward and reversed,
has been broadly used in research as a measure of work-
ing memory (Alloway et al., 2006). There is debate regard-
ing the nature of these measures. Some researchers propose
that digits forward and digits reversed rely on separate cog-
nitive abilities and that combining task scores obscures criti-
cal performance differences (Lezak et al., 2012; Reynolds,

6. 1997). Other researchers argue that the digit span tasks tap
into the same cognitive processes (Rosen & Engle, 1997;
St. Claire-Thompson & Allen, 2013). Beyond digit span
tasks, memory is often assessed using word list learning
tasks, such as the Verbal Paired Associates I and II subtests
in the Wechsler Memory Scale–Fourth Edition (WMS-IV;
Wechsler, 2009) and California Verbal Learning Test (Delis,
Kramer, Kaplan, & Ober, 1987). Although these tasks pro-
vide more information regarding episodic and semantic mem-
ory skills (Tayim, Flashman, Wright, Roth, & McAllister,
2016), they do not necessarily reflect real-world memory
demands, such as active recall of personal events.
Story Retelling in Individuals With mTBI
Relative to digit or word list recall, story retelling is
a complex task integrating multiple cognitive–linguistic
skills. The person must remember not only specific details
but also sequence and thematic information. The Logical
Memory subtests of the WMS-IV (Wechsler, 2009) include
both an immediate recall and a surprise delayed recall of
the stories. The delayed recall allows the assessment of lon-
ger term encoding and retrieval of complex narrative infor-
mation. Story recall tasks seem analogous to the memory
demands of academic and work environments, in which in-
dividuals must frequently remember information from lec-
tures or conversations. The Wechsler Memory Scale has
frequently been used to assess veterans with TBI (Burriss
et al., 2008; Ryan, Lee-Wilk, Kok, & Wilk, 2011). Using
the Logical Memory subtest, Burriss et al. (2008) found
that combat veterans with PTSD performed poorer on the
delayed recall portion than combat veterans and noncombat
veterans with no PTSD diagnosis. The researchers included
depression as a covariate in their analyses, but they did not
account for history of mTBI in their sample.

7. Although the Wechsler Memory Scale provides infor-
mation regarding general memory abilities, standard scaled
scores alone may not reveal important aspects of the mem-
ory deficit. Standard raw scores are based on counts of
informational unit chunks, which can include more than
one specific detail. For example, informational chunks fre-
quently combine numbers and units of measures (e.g., “four
inches”), yet each chunk is counted as a single item for scor-
ing. The count of informational chunks does not differenti-
ate the recall of specific information (i.e., the person may
recall the measurement of “inches” but fail to correctly re-
call the number “four”). By merging meaningful elements
in a story, relevant errors or inclusion of partial details may
be missed in the calculation. Standard scoring also does not
provide information regarding self-cueing strategies. Ana-
lyzing the content of other utterances may provide insight
into the individual’s episodic memory retrieval process.
486 American Journal of Speech-Language Pathology • Vol. 27
• 485–494 • March 2018
Including these additional measures in the scoring of recall
responses may provide a more complete memory profile for
veterans with mTBI.
Story retelling and narrative analysis have long been
utilized to assess cognitive–linguistic deficits associated
with moderate and severe TBI in the absence of aphasia
(Chapman et al., 1992; Coelho, Grela, Corso, Gamble, &
Feinn, 2005; Marini et al., 2011). Researchers report that
microstructural aspects of narrative production are gener-
ally commensurate with those produced by non-brain-injured
peers, but global measures, including content information
unit (CIU), efficiency measures, and story grammar analy-

8. ses, are more sensitive to mTBI-related deficits (Carlomagno
et al., 2011; Marini, Zettin, & Galetto, 2014; Matsuoka
et al., 2012). Recently, Galetto, Andreetta, Zettin, and
Marini (2013) compared 10 adults with mTBI to non-brain-
injured peers across a variety of cognitive, linguistic, and
narrative assessments. They found no grammatical, lexical,
or phonological differences between the groups, but the
mTBI group scored significantly poorer than controls in
story grammar measures. Overall, the results suggest that
narrative analysis is appropriate and sensitive to deficits
related to mTBI severity. Because these studies focused on
story grammar and CIU analysis of spontaneous discourse,
picture-based stimuli were used to elicit the narratives.
For studies that use single pictures to elicit spontaneous
discourse, the resulting responses may not provide mean-
ingful information regarding the individual’s episodic mem-
ory. Using picture series or nonverbal story presentations
can be effective in eliciting responses that reflect episodic
memory processes, but such stimuli seem less naturalistic
than verbal story presentation and recall.
Episodic Memory in Individuals With mTBI
Story retelling tasks are used to assess verbal episodic
memory in a variety of populations. Davis, Alea, and Bluck
(2015) examined accuracy in socially relevant story retell-
ing, with productions coded for both gist and detail accu-
racy. Their study focused on aging and gender effects, but
other researchers similarly examined recall of narrative
details in individuals with TBI. Kennedy and Nawrocki
(2003) compared recall of details and main ideas in TBI
survivors and healthy controls. In responding to gist and
fact questions, the TBI group were less accurate in their
recall than the control group. Successful strategic retrieval
of complex information from episodic memory relies on
higher order abilities that are associated with prefrontal

9. areas, the same frontal areas and networks that are fre-
quently damaged in TBI (Stuss, 2011). Episodic memory
retrieval deficits are often observed in individuals with TBI,
including those with mTBI (Miotto et al., 2010; Tayim
et al., 2016). However, the deficits associated with mTBI
may be difficult to detect using broad measures or stan-
dardized test scores. A more refined examination may be
required to assess subtle differences in overall productivity,
efficiency, and recall strategies. Self-cueing strategies have
been promoted to facilitate the recall of verbal information
and improve discourse production. For example, Antonucci
(2009) discussed the effective use of semantic features analy-
sis (SFA) as a self-cueing strategy in discourse. Wambaugh,
Mauszycki, Cameron, Wright, and Nessler (2013) included
a discourse task and CIU measurement in their treatment
study on SFA in individuals with chronic aphasia. They
specifically utilized a “mediating strategy” treatment fol-
lowing the more traditional SFA treatment. Because the
discourse sample was semantically unrelated to the trained
SFA stimuli, the researchers observed that the SFA skills
did not directly improve lexical retrieval but, rather, were
utilized as a self-cueing strategy. Several participants in-
creased efficiency in terms of words per minute without a
corresponding increase in relevant content—a pattern indic-
ative of self-cueing. Semantic self-cueing warrants further
examination in the context of episodic memory given the
connection between semantic processing and memory encod-
ing and retrieval (Craik and Tulving 1975; Greenberg &
Verfaellie, 2010; Nelson, Kitto, Galea, McEvoy, & Bruza,
2013). Similar to Wambaugh et al. (2013), the current study
analyzed the number of correct ideas produced by partici-
pants in the story retelling task. Additionally, an examina-
tion of the total number of words produced during story
recall may provide a measure of self-initiated, retrieval strat-
egies. A participant who uses self-cueing strategies through-

10. out recall should produce more words than a participant
who stops initiating, or never initiates, self-cueing strategies.
Aims
The primary purpose of this study was to determine
whether detailed analysis of story recall performance re-
veals significantly poorer performance in military veterans
with a history of mTBI compared with veterans without a
history of mTBI. The specific aims and hypotheses of the
study were as follows:
1. To examine whether standard scaled scores reveal sig-
nificant differences between veterans with mTBI and
control veterans. It was hypothesized that the stan-
dard scaled scores of the Logical Memory 1 and 2
would not be sensitive to mTBI deficits, and no group
differences would be observed in either the immediate
or delayed recall conditions.
2. To determine whether more detailed analysis of cor-
rect information produced would detect differences
between the mTBI and control groups across recall
conditions. It was hypothesized that group differ-
ences would not be observed in the immediate recall
condition, but veterans with mTBI would produce
fewer correct idea units than control veterans in the
delayed recall condition. This pattern would suggest
that mTBI impacts longer term encoding of verbal
information more than working memory storage.
3. To assess differences between the mTBI and control
groups in word production across the immediate and
delayed recall conditions. It was hypothesized that
the groups would be similar in word production in

11. Gallagher & Azuma: Story Recall in Veterans With TBI 487
the immediate condition, but the control group will
produce more words than the mTBI group in the de-
layed condition. This difference in word production
would be related to the increased use of self-cueing
strategies in the control group relative to the mTBI
group.
Method
Participants
Twenty-one military veterans enrolled as undergradu-
ate students at Arizona State University participated in this
study. Participants were recruited via e-flyers sent through
the ASU Pat Tillman Veterans Center. Veterans were all
Post-9/11 GI Bill benefit eligible students, who were work-
ing on their first college degrees. All participants completed
an online survey that included questions on their educa-
tional, military service, and medical history. As part of the
questionnaire, participants were asked to provide a self-
rating of their memory. The question stated: “Select the
statement that best describes your OVERALL memory
(your memory in your everyday life)”: 5 = My memory is
much better than other people my age; 4 = My memory is
somewhat better than other people my age; 3 = My mem-
ory is about the same as other people my age; 2 = My memory
is somewhat worse than other people my age; 1 = My mem-
ory is much worse than other people my age. Self-ratings of
1 or 2 were considered indicative of memory difficulties.
Seven of the 21 participants reported history of mTBI,
either diagnosed or undiagnosed. Undiagnosed mTBI was
verified based on responses to questions regarding symptoms

12. included on the Mayo Classification System for Traumatic
Brain Injury Severity (Malec et al., 2007) and the American
Congress of Rehabilitative Medicine. Specific symptom self-
report related to a described blast injury or head trauma
included loss of consciousness less than 30 min, posttrauma
anterograde amnesia of less than 24 hr, or a combination
of blurred vision, confusion, dazed, dizziness, nausea, or
headache. No participant reported a history of stroke or
other neurological impairment. All participants reported
normal or corrected-to-normal vision and hearing. Demo-
graphic information for veterans with and without his-
tory of mTBI is shown in Table 1. The groups did not
significantly differ in age, t(19) = −1.31, p = .205, grade point
average (t < 1), number of college credits earned (t < 1), or
number of months between high school graduation/General
Equivalency Diploma (GED) and enrollment in first college
class (t < 1). Prior to testing, a certified speech-language
pathologist judged articulatory accuracy, rate of speech,
and vocal quality during conversational speech. All partici-
pants were judged to have “no perceptible speech or vocal
parameters indicative of a possible disorder.”
Procedure
Logical Memory I and II
All participants were administered Stories B and C
from the Logical Memory I (LM I) and Logical Memory II
(LM II) subtests from the WMS-IV as part of a larger
battery of cognitive testing. The entire cognitive testing ses-
sion lasted approximately 90–120 min (duration was depen-
dent on the number of requested breaks). For the LM I
subtest (Immediate Recall), the participant was told two
stories. Both stories were orally presented by the researcher
with no visual cues. Immediately after each story, the par-
ticipant was asked to recall the story in as much detail as

13. possible, using as many of the same words as they could re-
member. The participant was not told that they would be
required to retell the story following a delay. For the LM II
subtest (Delayed Recall), the participant was asked to recall
each story again following a 20–30-min delay. Between the
immediate and delayed recall, participants completed an
unrelated computerized task involving math or spatial judg-
ments or a pencil-and-paper survey. All recall responses
were digitally recorded for transcription and later scoring.
Two researchers independently transcribed the stories ver-
batim, including all interjections, mazes, and comments.
Discrepancies between the two transcriptions were resolved
by a third transcriber.
Scoring
Standard scaled scores reflected scoring that followed
the WMS-IV manual for conversion to scaled scores and
were calculated by two independent scorers who were trained
in WMS-IV procedures. Discrepancies were resolved by a
third scorer trained in the procedures. The transcriptions
were then scored for number of total correct ideas and total
Table 1. Demographic information for veteran control and mTBI
groups (range in brackets).
Characteristic Control veterans (n = 14) Veterans with mTBI (n
= 7)
Age in years (SD) 29.29 (3.2) 32.57 (8.4)
Mean GPA (SD) 3.08 (0.57) [2.21–4.00] 3.08 (0.57) [2.50–4.00]
Mean college credits earned (SD) 86.5 (56.8) [6–167] 92.6
(75.6) [0–196]
No. of months before college enrollment (SD) 50.7 (32.6) [3–
108] 42.4 (47.1) [0–120]
No. of males (%) 7 (50.0%) 7 (100%)

14. No. reporting PTSD (%) 3 (21.4%) 3 (42.9%)
No. reporting depression (%) 4 (28.6%) 3 (42.9%)
No. reporting memory problems (%) 5 (35.7%) 5 (71.4%)
Note. Number of months before college enrollment: number of
months between high school graduation/General Equivalency
Diploma (GED)
and enrollment in first college class. mTBI = mild traumatic
brain injury; GPA = grade point average; PTSD = posttraumatic
stress disorder.
488 American Journal of Speech-Language Pathology • Vol. 27
• 485–494 • March 2018
words produced, measures developed to more discretely
analyze productivity and efficiency as related to the story
content. Total correct ideas reflected the number of correct
individual facts recalled from each story. Ideas were clas-
sified into specific informational units for scoring. For ex-
ample, the story excerpt “she had four small children, the
rent was due, and they had not eaten for two days” con-
tained the idea units: 1) four, 2) children, 3) rent was due,
4) had not eaten, 5) two, 6) days. This scoring of correct
ideas differs from the standard score calculation specified in
the WMS-IV manual in that specific ideas were each counted
separately rather than part of a group of ideas. For exam-
ple, in the standard logical memory (LM) scoring, “two
days” is counted as one concept, and scoring allows for any
phrase indicating “a couple of days.” Two independent
raters scored all transcriptions for total correct ideas. Across
the 80 transcriptions, there was 93.75% agreement between
the two scorers. No discrepancy was greater than 1 point,
and score discrepancies were either resolved through a re-
peated scoring of the transcript or discussion between the

15. scorers. Total words produced reflected the total number
of words that the participant used to retell the story. Filler
words (e.g., “um”), phrases unrelated to the story content,
and phrases indicating the participant had stopped trying
to retrieve story information (e.g., “I don’t remember any-
thing more.”) were not included in the count. However, any
phrases that reflected continued attempts to retrieve story
information (e.g., “I don’t know the word exactly…” and
“I’m trying to remember the city…”) or semantically related
to the story content were included in the count. For exam-
ple, the statement, “…was she robbed? I think she was
robbed on 5th Street.” All transcriptions were scored by
two independent scorers for total words produced with
98.75% agreement between the scorers.
Results
To examine group differences in production in the
two recall conditions, a 2 (Delay Condition: Immediate vs.
Delayed) × 2 (Group: Control vs. mTBI) mixed-factor
analysis of variance (ANOVA) was conducted on each
measure. Pairwise comparisons between mTBI and control
groups were evaluated with independent-groups t tests.
Pairwise comparisons between immediate and delayed
in Table 2 shows the mean LM scaled scores, total cor-
rect ideas, and total words for both groups across delay
conditions.
LM Scaled Scores
The 2 (Delay Condition) × 2 (Group) ANOVA con-
ducted on LM scaled scores revealed no significant effect
of delay, F(1, 19) = 3.13, p = .093, η2 = .142. Overall, there
was no difference in immediate versus delayed perfor-
mance. There was no significant effect of group: The two
groups did not differ in overall recall performance (F < 1).

16. The interaction between the variables was marginal, F(1, 19) =
4.54, p = .07, η2 = .163. Post hoc analysis (analysis of
covariance [ANCOVA]), including Gender, PTSD, and
Depression as covariates revealed no significant associated
differences in LM scaled scores and no significant inter-
actions with delay (all Fs < 1).
Total Correct Ideas
The 2 (Delay Condition) × 2 (Group) ANOVA con-
ducted on the total correct ideas revealed a significant
main effect of delay, F(1, 19) = 22.21, p < .001, η2 = .539.
Significantly more correct ideas were recalled in the imme-
diate condition relative to the delayed condition. The effect
of group was not significant (F < 1). Overall, the two
groups performed equivalently. However, there was a
significant Delay × Group interaction, F(1, 19) = 4.54,
p = .047, η2 = .193. To examine the nature of the interaction,
pairwise comparisons were conducted using repeated-
measures t tests (for immediate vs. delay comparisons) and
independent-groups t tests (for group comparisons). The
control group produced more total correct ideas in the im-
mediate versus the delay conditions, t(13) = 2.50, p = .025.
The mTBI group similarly produced more correct ideas
in the immediate condition, t(6) = 3.60, p = .013, but
showed a larger drop between the immediate and delayed
conditions than the control group (mean delay differ-
ence: mTBI = 7.00 vs. control = 2.65). Post hoc analysis
(ANCOVA), including Gender, PTSD, and Depression as
covariates revealed no significant associated differences
in correct ideas and no significant interactions with delay
(all Fs < 1). See Figure 1 for mean LM scaled scores and
total correct ideas for both groups.
Total Words Produced

17. The 2 (Delay Condition) × 2 (Group) ANOVA con-
ducted on total words produced revealed a significant effect
of delay, F(1, 19) = 1.14, p = .03, η2 = .057. More total
words were produced in the delayed condition than in the
immediate condition. There was also a significant effect of
group, F(1, 19) = 4.46, p = .05, η2 = .19, with the control
group producing significantly more total words than the
mTBI group. A significant Delay × Group interaction was
also observed, F(1, 19) = 5.08, p = .036, η2 = .211. Addi-
tional pairwise comparisons were conducted to examine
the nature of the interaction. In the immediate condition,
the control and mTBI groups did not significantly differ
in total words (t < 1, p = .364). However, in the delayed
condition, the mTBI group produced significantly fewer
total words relative to the control group, t(19) = 2.60,
p = .018. This group difference was driven by the control
group producing more total words in the delayed versus
immediate conditions, t(19) = −2.59, p = .022; a difference
not observed for the mTBI group (t < 1, p = .508). Post
hoc analysis (ANCOVA), including Gender, PTSD, and
Depression as covariates, revealed no significant associated
differences in total words produced and no significant
interactions with delay (all Fs < 1). See Figure 2 for mean
Gallagher & Azuma: Story Recall in Veterans With TBI 489
total words produced across delay conditions for both
groups.
Discussion
In our sample of military veterans, analysis of LM
scaled scores did not reveal significant performance dif-

18. ferences between the mTBI and control groups. The LM
scaled scores generally fell within 1.5 SDs of the mean. Be-
cause most studies only analyze scaled scores, the lack
of mTBI effect on LM scaled scores is consistent with pre-
vious studies reporting small (or no) enduring effects of
mTBI on neuropsychological test performance, even when
individuals self-report cognitive symptoms (Hartikainen
et al., 2010; Jak et al., 2015). Indeed, in our study sample,
71.4% of the mTBI group self-reported memory problems
versus the 35.7% of the control group. The LM standard
scoring procedures do not allow for the detection of re-
trieval failures or cueing strategies. Though subtle, these
retrieval impairments may nonetheless have important im-
plications for functional memory performance. Given that
accurate discourse retelling/recall is a critical skill in both
professional and social settings, any memory retrieval im-
pairment could have wide-ranging consequences.
In this study, story recall performance was further
analyzed using other measures that provided more detailed
response information, including total correct ideas and
total words produced. These additional measures revealed
diverging response patterns for veterans with and without
history of mTBI. For total correct ideas, the control and
mTBI groups both produced more correct ideas in the im-
mediate condition than in the delay condition, but the
mTBI group showed a larger drop after the delay. The lower
recall performance after a delay observed in the mTBI group
is consistent with previous findings related to mTBI (Fisher,
Ledbetter, Cohen, Marmor, & Tulsky, 2000) and more severe
TBI (Carlozzi, Grech, & Tulsky, 2013). Thus, the detrimental
effect of delay on story recall seemed to impact the veterans
with mTBI more than the control veterans. Immediate recall
was less likely to be affected in mTBI as it relies more strongly
on rehearsal strategies and short-term storage of information.

19. In contrast, accurate recall of information following a delay
requires appropriate encoding and retrieval of the individual
story elements, the semantic relationships among those ele-
ments, and the sequence of the events. These processes are
associated with the prefrontal cortex, an area commonly
affected by mTBI (Stuss, 2011). The participants also com-
pleted unrelated tasks between the immediate and delayed
recall of the stories. Thus, the poorer recall of the mTBI
group in the delayed condition might reflect an increased
sensitivity to interference effects. Additional research with a
larger sample of veterans is needed to confirm the sensitivity
of this measure to the effects of mTBI on discourse memory.
Total words produced also revealed different response
patterns in veterans with and without a history of mTBI.
In the immediate condition, the two groups produced a sim-
ilar number of total words. However, after a delay, the vet-
erans in the mTBI group produced significantly fewer total
words than veterans in the control group. This group differ-
ence was primarily driven by the control veterans produc-
ing significantly more words in the delayed condition than
in the immediate condition. The total words produced in the
attempted recall of story information provide insight into
retrieval strategies employed by the participants.
An informal examination was performed to assess the
nature of the group differences in total words and self-cueing
Table 2. Mean logical memory scaled scores, mean total correct
ideas, and mean total words for veteran control and
mTBI groups across delay conditions (standard deviations in
parentheses; range in brackets).
Delay condition
Control
veterans

20. Veterans
with mTBI
Group difference
(mTBI–control) t-test results
LM scaled score: immediate 8.21 (3.5) 8.71 (2.1) +0.50
[1.0–12.0] [5.0–11.0]
LM scaled score: delayed 8.29 (2.9) 7.00 (3.1) −1.29
[3.0–13.0] [4.0–11.0]
Delay difference +0.08 −1.71
(Delayed–immediate)
Total correct ideas:
immediate
21.29 (9.0) 21.71 (4.6) +0.42 t(19) = .117, p = .908
[7.0–33.0] [13.0–26.0]
Total correct ideas:
delayed
18.64 (8.3) 14.71 (6.9) −3.93 t(19) = 1.08, p = .294
[4.0–31.0] [7.0–25.0]
Delay difference −2.65* −7.00*
(Delayed–immediate) t(13) = 2.50, p = .025 t(6) = 3.60, p =
.013
Total words:
immediate
88.36 (28.0) 74.86 (14.7) −13.50 t(19) = 0.929, p = .364

21. [31–125] [56–95]
Total words:
delayed
106.36 (37.5) 68.43 (16.9) −37.93* t(19) = 2.60, p = .018
[30–167] [43–85]
Delay difference +18.00* −6.43
(Delayed–immediate) t(19) = −2.59, p = .022
Note. mTBI = mild traumatic brain injury; LM = logical
memory.
*p < .05.
490 American Journal of Speech-Language Pathology • Vol. 27
• 485–494 • March 2018
in the delayed recall condition. Of the 14 control veterans,
nine (64%) showed evidence of self-cueing attempts in the
form of extraneous, but story-relevant, phrases. For exam-
ple, one control veteran stated, “…she had been robbed
or mugged, or held up.” The distinction between being
“robbed” and “held up” is significant in the standard
WMS-IV scoring. Other control veterans demonstrated
attempts at phonemic self-cueing (e.g., “Was it an M state?
Figure 1. Mean standard scores (top panel) and total correct
ideas (bottom panel) for veteran control and mTBI groups
across immediate and delayed conditions. mTBI = mild
traumatic brain injury.

22. Gallagher & Azuma: Story Recall in Veterans With TBI 491
Missouri?” “Her last name starts with a B, I think…”) or
semantic self-cueing (e.g., “…they felt, I don’t know the
word exactly, but compelled to take up a collection for
her…”). In contrast, only two (28.6%) of the seven mTBI
participants showed any evidence of self-cueing attempts
in their delayed recall. Some veterans with mTBI provided
very sparse responses with no attempt to retrieve beyond
a few basic ideas, such as “I believe his name was Joseph or
Joe and he caught a weather statement on the news of in-
clement weather” and “I just remember Garcia.” Others
stated their difficulty in remembering the story details but
did not actively try to retrieve the information. For exam-
ple, one veteran with mTBI responded, “A girl was robbed,
I can’t remember the name of the street nor can I remember
the time. [I can’t remember. That’s all I have].” The brack-
eted extraneous comments reflect no attempt at self-cueing or
additional retrieval strategies. Because such story-irrelevant
comments were not included in the total word measure, the
group difference in the delayed condition suggests that the
control veterans were more likely to engage in self-initiated
retrieval strategies than veterans with mTBI. This finding
is consistent with previous studies that focused on the use
of self-cueing strategies in individuals with TBI (Miotto et al.,
2012; Ptak, van der Linden, & Schnider, 2010). An alternative
explanation for the decreased self-cueing observed in the
mTBI group is that the participants had simply provided all
of the information they had stored and no amount of self-
cueing would be effective. Additionally, it is possible that
participants engaged in internal retrieval strategies that
were not reflected in their verbal responses.
The patterns observed for both additional measures

23. are complementary: The veterans with mTBI produced
fewer correct ideas and fewer total words than control vet-
erans, but only when recall of the information was delayed.
Including the analysis of total words and correct ideas
along with scaled scores in story recall responses could re-
veal subtle memory deficits in veterans reporting unremit-
ting mTBI symptoms. Indeed, the nature of impairments
associated with mTBI may warrant more detailed analysis
of narrative recall in veterans with mTBI. LM scaled
scores are based on counts of larger units of information,
which may overestimate or underestimate memory retrieval
success. Subtle mTBI deficits may only be discernable
when smaller units of meaning are analyzed. Retrieval fail-
ure of small information units can have large consequences.
For example, it is a nontrivial matter if one recalls “two
days” as “two weeks.”
Another possible influential factor in memory perfor-
mance in our veteran groups is the presence of concomitant
service-related conditions, such as PTSD (Burriss, Ayers,
Ginsberg, & Powell, 2008; Cooper et al., 2015). In our sam-
ple, the proportion of veterans reporting PTSD was higher
in the mTBI group (n = 3) than in the control group (n = 3).
Given that PTSD has been shown to be a significant vari-
able affecting cognitive performance in individuals with
mTBI (Lange et al., 2012; Nelson et al., 2010; Verfaellie
et al., 2014), post hoc analyses examining PTSD were con-
ducted on our study sample. When the veterans were sepa-
rated into PTSD (n = 6) and no PTSD (n = 15) groups,
no significant differences were observed for any measure
Figure 2. Mean total words produced for control and mTBI
groups across immediate and delayed conditions. mTBI =
mild traumatic brain injury.
492 American Journal of Speech-Language Pathology • Vol. 27

24. • 485–494 • March 2018
(LM I and LM II scaled scores and correct ideas, all t < 1;
total words for LM II, t(19) = 1.31, p = 2.06). Additionally,
when the primary analyses were repeated with PTSD in-
cluded as a covariate, PTSD did not account for a signifi-
cant amount of the variance (all F < 1).
The findings of this preliminary study have implica-
tions for assessment and treatment but require confirmation
with a larger sample of veterans. In our study, the delay-
associated memory decline seems to reflect both difficulties
in the retrieval of ideas and failure to actively engage in
self-cueing. If this pattern is observed during assessment,
clinical intervention could focus on strengthening the encod-
ing of information and increasing the use of retrieval strate-
gies. Future research could also investigate the role of
executive function in episodic memory retrieval of narra-
tive discourse. Previous researchers have attributed episodic
memory impairments related to mTBI to executive func-
tion deficits associated with TBI (Miotto et al., 2010; Tayim
et al., 2016). Executive function can also affect other as-
pects of memory recall performance. For example, execu-
tive function may be related to the probability of self-cueing
strategy use. Future studies should investigate the role of
executive function in the successful retrieval of discourse
information from episodic memory. Narrative discourse
analysis might also provide additional insight into mTBI-
related deficits. Although narrative discourse analysis of
spontaneous speech has been shown to be a sensitive mea-
sure for TBI (Chapman et al., 1992; Coelho et al., 2005;
Jorgensen & Togher, 2009; Peach & Coelho, 2016), it is less
often used to specifically examine episodic memory perfor-
mance for orally presented discourse. Such analyses may

25. further elucidate the nature of cognitive–linguistic deficits
related to mTBI.
As previously noted, military veterans with mTBI
can report chronic cognitive symptoms that may not be
confirmed by standard neuropsychological assessments.
This study demonstrates that additional measures of mem-
ory recall performance can reveal mTBI effects that are
not observed when only standard scale scores are consid-
ered. These more detailed measures can provide more spe-
cific information regarding the nature of the memory
difficulties experienced by veterans with mTBI.
Acknowledgments
The authors would like to thank the staff and leadership at
the Pat Tillman Veterans Center at Arizona State University.
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Aztecs for Literacy

34. Name
Name
Name
Problem
As students of San Diego State University, we believe education
is fundamental for everyone around the
world to acquire. Books are what build us. We gain knowledge
through reading, whether it is
educational or for leisure. Here in the United States, we can
borrow books from libraries for free. We
were given books in elementary school. However, in Africa,
children do not have the same opportunity.
Africa is filled with many poor communities, many of which do
not own books. There are nearly 128
million schooled-aged children. Of that number, 17 million have
never attended a school. What is more
shocking is that another 37 million African children will learn
so little while they are in school due to the
lack of books.
For many children in Africa, receiving a book is a gift, a gift of
hope. Most African children who attend
school have never owned a book of their own. In many
classrooms, 10-20 students share one textbook.
Many people in the United States take these educational
necessities for granted, but children in Africa

35. treasure books. For many, having access to an education is a
solution of transcending poverty and
acquiring a better quality of life than their previous generations.
Therefore, without books, children are
not able to acquire an education, which means they can’t
become better individuals. The lack of books is
a reality in Africa today. As of today, there are 370 million
children living in Africa. Without our help,
many will never have access to books. Without our help,
another generation of African children will
grow up without books.
Solution
To address this problem, we propose to create the group Aztecs
for Literacy. The group Aztecs for
Literacy would be a student group where students, teachers, and

36. others in the community could
collaborate with the organization called Books for Africa. We
intend to persuade San Diego State
University’s Associated Students (AS) to allow our group to be
an SDSU student organization. Aztecs for
Literacy’s main purpose will be to get students, teachers,
faculty, etc. to donate books to send to
children in Africa. The organization will also accept donations
and financial help in order to make
sending these books possible. The Associated Students of San
Diego State University is always accepting
new student groups to make a difference. Currently, there are no
student groups working toward the
literacy of African children. Whether it be in the SDSU
community, or in another country in the world, it
is clear that Associated Students wants to make change and can
do so in the approval of Aztecs for
Literacy.
Aztecs for Literacy will be creating flyers to send and pass out
to students, teachers, faculty, and parents
as well as a website and a Facebook group for San Diego State
University students to ‘ like’ and/or join.
The goal is to reach all students and community members in
giving everyone the opportunity to

37. participate, whether that be through their membership in the
group, or simply by donating books or
funds. The flyers that we will be sending and passing out will
include our mission statement: “ Providing
literacy to students and children in Africa.” The flyers will
contain pictures of children in Africa that have
already been impacted by the cause so far, and ways in which
people can help out. We will include the
date of our first meeting that people can attend to see if they
want to become a member or simply help
out with the cause of our organization. In addition to passing
out and mailing out these flyers, we will
post them on bulletin boards and around campus.
In addition to the flyers, our website will be used to help people
learn more about the organization
and/or join. It will provide information on the need for literacy
in Africa, our mission statement, a list of
contributors, a background of the organization Books for Africa
that we are partnering with, a list of
people who have joined, and those that have already made
donations in books and financially. We will
have a link to send questions via email to our organization. The
Facebook page will be titled “Aztecs for
Literacy” and will provide the opportunity for people to “like”

38. the page in order to get the word out. In
addition, students and anyone interested may join the Facebook
group and learn about how they can
participate. We will hold monthly meetings where individuals
can sign up for the organization and
partake in the fundraising/book collecting process. In addition
to our flyers, website, and Facebook
page, our meetings will address our problems, mission
statement, and ways to help out. In these
meetings, individuals will have the chance to join our group, or
simply make a book donation or financial
donation. Flyers will be available at all times for people to pass
out to friends and acquaintances
potentially interested in helping the cause.
Aztecs for Literacy will be offering a membership to students
and teachers at a cost of $25 dollars. This
money will go towards the donation boxes we will have around
campus and the future shipping of
books. This fee will help give more value to obtaining a
membership in the organization. Helping out
doesn't have to be obtaining a membership, anyone can help out

39. through easy ways that don’t require
too much. We will have a few donation boxes set up around
campus where anyone can drop in used or
new books that they no longer need. In addition to this, we will
be accepting money donations via our
website, mail, and at our meetings as well. According to Books
for Africa, “ 50 Cents Sends a Book to a
Child in Africa.” We will have different types of fundraisers.
One specific fundraiser will be pairing up
with local fast food restaurants where people can go to a
restaurant and a certain percentage of the
price of their meal will go straight to our organization on a
specific day. We will advertise for this via
Facebook, our website, and flyers- anyone can take part through
a simple way. The solution to the need
for literacy in Africa is completely possible. The organization
Books for Africa states that “ It costs about
$10,300 to send a 40-foot sea container of books, computers,
and school supplies to most major African
sea ports.” The cost is very small in comparison to the
incredible solution. It will be possible as a result of
our planned fundraisers and donations. People are always
looking for new ways to help out. Children in
Africa are hungry to read and hungry to learn.

40. Benefits
Aside from the personal benefits that come from books, there
are many other benefits to having the
student group Aztecs Rock Literacy. Creating this group means
that any books that people have lying
around the house can be donated and put to use for a good cause
instead of thrown away. In addition, it
lessens the clutter on bookshelves and creates opportunities for
libraries elsewhere, more importantly
in Africa. According to the online bookstore, Better World
Books, they have diverted over 73,000 tons of
books found in landfills. This is a major issue because these
books could be potentially useful to a child,
an educator, or a family in need of books. Here in America we
take advantage of the accessibility we

41. have to books, magazines, and other print found in libraries all
over. This student group needs to be
created so that books can be given a new home and help lessen
congested bookshelves and backpacks.
Evidently, as more books and monetary donations are donated,
the more children in Africa are given the
opportunity to become literate and catch up to their peers in
school. This is very important because
illiteracy plagues many children and families in Africa.
According to the United States Agency for
International Development, 40% of school-age children do not
attend school or have even set foot in a
classroom. This leads to the sad fact that most African children
do not own a book of their own. The
students that are fortunate enough to attend school are forced to
share one book with their classmates.
Again, with the creation of this organization, we are able to
provide children with the greatest gift in the
world, a world of literacy starting with a book of their own.
Furthermore, the books that are collected
from book drives and donations, will not only be given to
children, but they will also be bestowed to
libraries in Africa. This will help the country make greater
strides in becoming self-sufficient by providing

42. literacy to their generations of people. The books that are not
age-appropriate for children can be used
for adult literacy programs and resource centers.
Illiteracy is an epidemic that we would like to help end with the
support of our fellow Aztecs and
surrounding community. The books donated from students,
faculty, and community members will help
our student organization aid the people in Africa in creating a
culture of literacy and providing tools of
empowerment for generations to come. In addition, students that
join our organization will acquire
many marketable skills such as financial development,
community outreach, and teamwork experience.
By approving our student group, Aztecs Rock Literacy, it
enables us to help enrich our experience and
jump-start the spark that changes the world we all live in.
RWS 305W Collaborative Proposal Project
Many San Diego State University students get involved with the

43. campus community by forming
student groups. According to SDSU’s website, there are over
300 student organizations on
campus that “cover a wide range of interests—recreation,
honors societies, cultural groups,
professional development organizations, multicultural
societies,” etc. To access this list of
groups, go to SDSU’s Home Page and from the Camus Life
drop-down menu, select “Get
Involved” and then select “Student Organizations.”
The ability to produce work collaboratively is a skill that is
highly valued in today’s workplace.
Working as a group, write a 1500 word proposal that seeks
approval from Associated Students to
form a new student group at SDSU. The purpose of your
organization should be to fill a need,

44. solve a problem, or provide growth opportunities for students
on campus. While you do not have
to follow through on forming this group, what you are
proposing should be realistic and feasible.
You will need to do some research on your issue. Explain how
funding will be obtained, such as
fundraising activities or appeals to organization for donations or
sponsoring. Be sure to address
the issue of sustainability. How will this organization be able to
exist after your group graduates?
This is usually accomplished by incentivizing students in
particular majors to become volunteers
and carry on the mission of the organization—either through
class credit or professional
development opportunities.

45. You will use the title page of your report to supply the Title of
your proposal, an image that is
relevant to your topic and adds to its persuasiveness, and the
names of your group members.
Organize your report around the following three main sub-
sections.
Problem or Need
Provide background information to introduce the issue you plan
to address or the
need you plan to fill. Keep it local. Keep your goals realistic
and feasible.