NEUROPSYCHOLOGICAL REHABILITATION

2007, 17 (3), 314– 334

Prospective memory in adults with traumatic

brain injury: An analysis of perceived reasons
for remembering and forgetting

Nadine L. Roche1, Anna Moody2, Krisztina Szabo2, Jennifer

M. Fleming1,2, and David H. K. Shum3
1
Occupational Therapy Department, Princess Alexandra Hospital, Queensland,
Australia; 2Division of Occupational Therapy, School of Health and
Rehabilitation Sciences, University of Queensland, Brisbane, Australia;
3
School of Psychology and Applied Cognitive Neuroscience Research
Centre, Griffith University, Queensland, Australia

Reasons for prospective remembering and forgetting after traumatic brain

injury (TBI) were investigated using Ellis’ (1996) five phases of prospective
memory as a framework. Participants were 38 individuals with severe TBI
and 34 controls. Participants self-rated their perceived reasons for prospective
remembering and forgetting using section C of the Comprehensive Assessment
of Prospective Memory (CAPM). Significant others also rated participants
using the same scale. Analyses were conducted to examine the effect of
group membership (TBI or control) on reported reasons for prospective remem-
bering and forgetting. Findings highlighted the TBI group’s difficulties with
encoding, performance interval, and execution phases of prospective
remembering.

Correspondence should be sent to Dr Jennifer Fleming, Senior Research Fellow, School of

Health and Rehabilitation Sciences, University of Queensland, Brisbane, Queensland 4072,
Australia. E-mail j.fleming@uq.edu.au
This research project was supported by funding from the Centre of National Research on Dis-
ability and Rehabilitation Medicine (CONROD) and the National Health and Medical Research
Council (NHMRC). The authors would like to thank Dr Jill White for her work in developing
the questionnaire, Ms Hannah Gill for her help with the data analysis, the occupational therapy
staff at Princess Alexandra Hospital for their assistance with data collection, and all of the par-
ticipants and their friends and relatives for taking part in the study.

# 2007 Psychology Press, an imprint of the Taylor & Francis Group, an Informa business
http://www.psypress.com/neurorehab DOI:10.1080/09602010600831004
 PROSPECTIVE MEMORY IN ADULTS WITH TBI 315

INTRODUCTION
Rehabilitation professionals and people with brain injury agree that memory
impairment is a common and persistent problem following brain injury
(Hutchinson & Marquardt, 1997; Mateer, Sohlberg, & Crinean, 1987;
Parente & DiCesare, 1991; Shum, Valentine, & Cutmore, 1999; Sohlberg
& Mateer, 1989; Thompson, 1996). Historically, research on memory follow-
ing brain injury has focused on retrospective memory (Shum, Fleming, &
Neulinger, 2002), or the ability to recall previously presented information
or past events upon request (Dalla Barba, 1993). However, there has been a
growing interest in prospective memory functioning (Baddeley, 2002;
Dobbs & Reeves, 1996; Ellis & Kvavilashvili, 2000; Mateer et al., 1987)
as the ecological validity of retrospective memory in representing the
memory skills required for everyday tasks is increasingly questioned
(Cohen, 1996; Dalla Barba, 1993; Mateer et al., 1987).
Prospective memory refers to the ability to remember to perform a pre-
planned action at a specific time in the future or in response to a specific
future event, while involved in another activity (Groot, Wilson, Evans, &
Watson, 2002). This skill is considered to be of great importance for every-
day memory function (Cohen, Kiss, & LeVoi, 1993; Ellis & Kvavilashvili,
2000; Kinsella et al., 1996; Winograd, 1987). In daily living situations,
people rely on prospective remembering to successfully maintain their
basic personal hygiene, ongoing employment, home safety and security,
and social relationships. Consequently, prospective memory failure can
yield damaging results. Most memory complaints from those with memory
impairments refer to prospective memory deficits (Wilson, 2003). People
without brain injury also complain of experiencing prospective memory
lapses, however such lapses have been shown to occur more frequently
after traumatic brain injury (TBI) (Roche, Fleming & Shum, 2002). The
present study aimed to further clarify the reasons for prospective remember-
ing and forgetting in persons with TBI and discuss the implications for brain
injury rehabilitation. In particular, the study aimed to look at how significant
others of people with TBI perceive the reasons for prospective memory
failure. This study is attached to a larger study, part of which has already
been published (Roche et al., 2002).

Stages of prospective memory

Einstein and McDaniel (1990) described two components to prospective
memory tasks. The first part is the retrospective component. This involves
remembering what actions are to be carried out and the cuing event for the
elicitation of that action. The second component involves the recall and
initiation of an action at the right time or in response to a specific cue. This
316 ROCHE ET AL.

entails remembering to actually carry out the action at the intended time. The
successful initiation and execution of a prospective memory task can depend
on the nature of the memory prompt or cue (Einstein & McDaniel, 1990).
Another theory of prospective memory was developed by Ellis (1996), who
proposed five phases of prospective memory: (a) formation and encoding
of intention and action, (b) retention interval, (c) performance interval, (d)
initiation and execution of intended action, and (e) evaluation of the
outcome. Phase (a) involves storing the content of the intention or the fact
that the individual has to do an action in the future and when to do it.
Phase (b) involves the time period between when the intention is stored
until a time when it can be potentially recalled and used. Phase (c) is the
time period in which the stored intention should be performed. Phase (d)
occurs within phase (c) and involves initiating and carrying out the intended
action. Phase (e) is when the outcome of the action is evaluated and recorded
for future reference. Ellis identified phases (a) and (c) as corresponding to the
two prospective memory stages proposed by Einstein and McDaniel
(Ellis, 1996).
Ellis (1996) proposed that within the phases of prospective memory there
are many variables that influence successful encoding. Variables include the
“what”, “that” and “when” of prospective memory tasks in the encoding
phase. The “what” component addresses the content of the actual memory
being encoded, “that” addresses the underlying awareness that something
has to be done in the future and the “when” refers to the context (e.g.,
time, location, environmental factors) involved when the encoding occurred.
Other variables include the complexity of the task and the motivation behind
that action.
Ellis (1996) argued that the nature of the person’s motivation influences
the level of commitment to initiating and ultimately completing a prospective
memory task. A person’s motivation is based on the value that he or she
places on the action and includes the possible benefits of the action and the
consequences of failing to perform the task. Motivation is also influenced
by the source of the intention whether it was generated by oneself, or
another individual, who it will benefit, and the relationship between those
involved. Motivation can be strengthened or weakened by the relationship
between the prospective memory task and the individual’s long-term goals
and values. Ellis (1996) also indicated that the interaction of all the aforemen-
tioned variables with each other and the prospective memory task also influ-
ences the success of prospective memory.
As well as a retrospective memory component, prospective memory
involves higher executive functions (Groot et al., 2002), implicating frontal
lobe involvement (Bradshaw & Mattingley, 1995). The frontal areas of the
brain are associated with executive functions that are necessary components
of prospective memory (Glisky, 1996). These include initiation of the motor
 PROSPECTIVE MEMORY IN ADULTS WITH TBI 317

component of the prospective memory task, persistence when unable to com-

plete the prospective task when originally intended, organisation, awareness,
planning, decision-making, and inhibitory control mechanisms (Mateer,
1999; O’Connell, Mateer, & Kerns, 2003). The role of executive functions
in prospective memory is especially significant as the frontal lobes are a
common site of injury in persons with TBI (Levin, 1995; Stuss & Gow,
1992; Varney & Menefee, 1993).

Using significant others’ ratings when assessing memory in

people with brain injury
In studies addressing memory impairment, the reports by significant others
are commonly used alongside self-ratings by people with brain injury due
to the potential for decreased self-awareness (Brown & Nell, 1992; Goldstein
& Polkey, 1992; Hendryx, 1989; Sunderland, Harris, & Gleave, 1984;
Varney & Menefee, 1993). The use of this method is further supported by
studies that have found family members or partners more accurate at evalu-
ating function than individuals with brain injury (Andrewes, Hordern, &
Kaye, 1998; Sunderland et al., 1984). There are, however, other studies
that have questioned the accuracy of significant others’ responses on rating
forms as well as the accuracy of individuals with brain injury (e.g., Bogod,
Mateer, & MacDonald, 2003) as significant others’ responses may
be biased or complicated by factors such as caregiver burden, stress and
fatigue.

Measures of prospective memory

The Prospective Memory Questionnaire (PMQ) is a self-report questionnaire
(Hannon et al., 1995). The PMQ has been shown to be a valid tool for differ-
entiating between people with brain injury and those without brain injury
(Hannon et al., 1995), however it does not address the processes involved
in memory failure or question what explanation can be given for prospective
remembering and forgetting (Waugh, 1999).
The Comprehensive Assessment of Prospective Memory (CAPM) was
designed to comprehensively evaluate prospective memory, not excluding
identification of the perceived underlying causes of prospective remember-
ing and forgetting (Waugh, 1999). The CAPM consists of three sections,
which respectively measure the frequency of prospective memory failure,
the perceived importance of such failures, and the perceived reasons for pro-
spective remembering and forgetting (Waugh, 1999). The third section,
namely “section C”, focuses on the reported reasons for prospective
memory successes and failures using Ellis’ model as a guide. It includes a
number of items that address the phases of Ellis’s model and the variables
that Ellis described as possibly influencing prospective memory task
318 ROCHE ET AL.

performance (e.g., motivation, distractions). Section C consists of 15 ques-

tions. Questions 1 to 9 address the encoding phase; questions 10, 11 and
12 address the retention interval; questions 13 and 14 refer to the perform-
ance interval; and question 15 refers to the evaluation of outcome phase,
according to Ellis’ model.
The previous publication outlines findings from section A of the CAPM,
which investigated the reported frequency of prospective memory failure in
persons with TBI (Roche et al., 2002). The current study reports on the
results of section C of the CAPM, which addresses the perceived reasons
underlying prospective memory failure.
Most of the available measures of prospective memory address the fre-
quency of prospective memory failures but do not take into account the
reasons why people forget. In the clinical setting, however, a clearer
understanding of the reasons why prospective memory fails would
greatly assist the rehabilitation of people with prospective memory impair-
ments. If clinicians were able to tap into the factors that trigger prospec-
tive memory breakdown, treatment could then, in turn, be more accurately
targeted. Additionally, a closer look at the reasons for prospective remem-
bering and forgetting would add to the theoretical base of prospective
memory. The aim of this study was to examine the factors underlying pro-
spective memory successes and failures in adults with TBI with reference
to the stages in Ellis’ model (using the CAPM), from the perspective of
participants with TBI and their significant others. Specific objectives of
this study were (1) to compare self-ratings with ratings by significant
others on reasons underlying prospective remembering and forgetting,
(2) to compare participants with TBI and control participants on reasons
underlying prospective remembering and forgetting, and (3) to analyse pat-
terns of perceived reasons for prospective remembering and forgetting in
participants with TBI and control participants, with reference to Ellis’
model.
It was hypothesised that there would be no significant differences between
self-reported reasons for prospective memory success or failure in partici-
pants with TBI and control participants, but there would be a difference in
significant others’ reports. It was also hypothesised that there would be
higher agreement between control group participants and their significant
others than between the TBI group and their significant others. With
regards to the comparisons relating to Ellis’ model (1996), a comprehensive
hypothesis was not formulated, however based on the nature of poor working
memory and distractibility post-TBI, it was anticipated that the TBI group
would be reported as having more prospective memory difficulty when
there was more than one item to remember; or when there was a longer
delay; or when there were more intervening activities during the retention
interval.
 PROSPECTIVE MEMORY IN ADULTS WITH TBI 319

MATERIALS AND METHODS

Design
A cross-sectional design with between and within groups comparisons was
used in this study. The between groups analyses compared the effect of
group membership (TBI or control) on reasons for prospective forgetting or
remembering using self-ratings and significant others’ ratings. Within
groups comparisons compared participants’ responses with their significant
others’ responses, and planned comparisons of responses on specific ques-
tionnaire items paired according to Ellis’ model (1996).

Participants
A total of 136 participants were included in the study in four subgroups (a TBI
group, significant others of TBI participants referred to as the “TBI-other”
group, a control group, and significant others of control participants referred
to as the “control-other” group). The first group consisted of 38 adults who
had sustained a severe TBI. Selection criteria for the TBI group included suf-
ficient English communication skills to complete the questionnaire and the
availability of a significant other who was willing to provide informant
responses.
Participants with TBI were recruited to this study if they were past inpa-
tients or current outpatients at a major metropolitan public hospital in Bris-
bane, Australia. Severe TBI was determined by period of coma, initial
Glasgow Coma Scale (GCS) score of less than 8, or post-traumatic amnesia
(PTA) for greater than 24 hours. Participants with TBI were included in the
study once they had been discharged from inpatient care and had been
living in the community for at least four weeks to ensure they had some
post-injury experience outside of the hospital environment.
The second group consisted of 34 control participants who were closely
matched on age, gender, and years of education. Participants in the control
group were recruited from the researchers’ local community and social net-
works, not from health related services. Purposive and convenience sampling
was used in order to demographically match the control group with the TBI
group on the variables of age, gender, and years of education. A control par-
ticipant was excluded if he or she reported a history of brain injury.
There were no significant differences between the TBI group and control
group on age, gender or years of education. There was a comparable ratio
of males to females (26% females and 74% males in the TBI group, and
21% females and 79% males in the control group) and the same mean age
of 28 years (SD ¼ 10.5 years for the TBI group, SD ¼ 11.0 years for the
control group), and a mean of 10.9 years of formal education (SD ¼ 1.9 for
320 ROCHE ET AL.

the TBI group, SD ¼ 1.3 for the control group). The demographic character-
istics of this sample are representative of the brain injured population in
Australia (Fortune & Wen, 1999).
For the TBI group, the causes of TBI included motor vehicle accidents
(52.6%), being hit by a vehicle (15.8%), falling from a moving animal or
vehicle (13.2%), motor cycle accidents (7.9%), falls (2.6%), alleged assault
(2.6%), penetrating injury (2.6%), and light airplane accident (2.6%). The
initial mean GCS was 5.1 (SD ¼ 2.4, range ¼ 3– 11), PTA lasted an
average of 62.6 days and ranged from 9 to 185 days (SD ¼ 46.8 days). TBI
participants spent an average of 41 days in acute care (SD ¼ 28 days,
range ¼ 5 –106 days), an average of 60 days in rehabilitation (SD ¼ 57
days, range ¼ 0– 228 days), and were an average of 57 weeks post-injury
(SD ¼ 36 weeks, range ¼ 11 – 169 weeks) when they participated in this
study. Fifty percent had neurosurgery.
Each participant from the two groups nominated a significant other
(family member or friend) to also participate in the study. Thirty-four signifi-
cant others from the TBI group and 30 significant others from the control
group participated. The “TBI-other” group included 14 mothers, 7 wives,
5 fathers, 4 husbands, 1 sister and 3 unspecified relationships or missing
data. The “control-other” group included 11 mothers, 7 wives, 3 husbands,
1 father, and 8 unspecified relationships or missing data. There were no sig-
nificant differences in the proportion of parents, spouses or “other” relation-
ships in the TBI-other and control-other groups. All significant others were
asked to rate how well they felt they knew the participant on a four-point
scale – extremely well, very well, reasonable well, or only a little. In the
TBI-other group (n ¼ 34), 27 rated as knowing the participant extremely
well, 5 as very well, and 1 as reasonably well (1 other had missing data).
In the control-other group (n ¼ 30), 12 rated as knowing the participant
extremely well, 6 as very well, and 2 as reasonably well (10 others had
missing data).

Measures
This study used section C of the Comprehensive Assessment of Prospective
Memory (CAPM), which measures the processes involved in prospective for-
getting and remembering. Section C of the CAPM was derived from Ellis’
theory (1996) about the phases of prospective memory and was designed to
elicit information about the encoding, retention interval, performance inter-
val, initiation and execution of the intended action, and the evaluation of
outcome. Section C consists of 15 questions that are presented in Table 1
with a key to indicate which phases and variables of Ellis’ theory each ques-
tion addresses. On each of the items the participant is required to report how
strongly he or she is in agreement with the statements on a four-point scale in
 PROSPECTIVE MEMORY IN ADULTS WITH TBI 321

TABLE 1
Components of the comprehensive assessment of prospective memory, section C and
corresponding aspects of Ellis’ model

1. When I forget to do something I had planned to do, it is usually not because I forgot what I had to
do but because I forgot when I had to do it. (a(i))
2. When I forget to do something I had planned to do, it is usually because I forgot what I actually had
to do. (a(i))
3. I frequently forget to do things that other people have asked me to do. (a(ii))
4. I frequently forget to do things that I have planned to do. (a(ii))
5. If something is very important to me I usually remember to do it. (a(iii))
6. If something is very important for other people, I usually remember to do it. (a(iii))
7. The more things (say two or three) I have to do, the more likely I will forget to do them. (a(iv))
8. I rely on other people to remind me when I have to remember to do things. (a(v))
9. I do not need to rely on aids such as a diary or to-do list when I have to remember to do things.
(a(v))
10. If I have to do one thing in the immediate future (within the next half hour), I usually remember to
do it. (b)
11. I tend to forget to do things if there is a long delay before they need to be done (e.g., if I plan to do a
task in three weeks time). (b)
12. I tend to forget to do things if a lot of other activities take place before they need to be done. (b)
13. If I am engrossed in another task, I find it difficult to remember to do things. (c)
14. Sometimes even though I remember that something has to be done, I forget to do it if I am
interrupted (e.g., by a telephone call or by a person). (c)
15. I do not usually need to check whether I have done something because I am confident of my own
memory. (d)

a ¼ Formation and encoding of intentions

(i) ¼ what, that and when
(ii) ¼ self versus others’ initiation
(iii) ¼ motivation
(iv) ¼ complexity
(v) ¼ encoding
b ¼ Retention interval
c ¼ Performance interval, and execution of intended actions
d ¼ Evaluation of outcome

which 1 ¼ strongly disagree, 2 ¼ disagree, 3 ¼ agree, and 4 ¼ strongly

agree.
The CAPM was originally designed for use with the elderly population,
however it has been tested on young to middle aged adults (n ¼ 327) as
well as elderly adults (n ¼ 200) (Waugh, 1999). Waugh (1999) found
section C of the CAPM was sensitive in discriminating between age
groups, and had demonstrated internal consistency.
The significant others’ version of the questionnaire contains the same
items as the original questionnaire, but asks the significant other about the
participant’s prospective memory (e.g., If something is important to your
relative/friend, he/she usually remembers to do it).
322 ROCHE ET AL.

Procedure
Ethical clearance was obtained from the relevant university and hospital
ethics committees. All participants and significant others were provided
with information about the study prior to providing written consent.
Participants with TBI completed the questionnaire in either a quiet non-
distracting environment in the hospital or, on occasion, via telephone for
those who were unable to visit the hospital. The study was first explained
to participants by the researcher and assistance to complete the questionnaire
was provided to persons with cognitive deficits as necessary. For participants
who completed the questions via telephone interview, time was taken by the
interviewer prior to commencement to ensure the participant wrote down
each of the response options and corresponding definitions for his or her
reference when answering each question, thus providing a visual reminder
of all the response options throughout the duration of the questionnaire inter-
view. Significant others completed their questionnaires independently at
either the same time as the participants with TBI or at home and returned
the questionnaires via reply paid mail. Participants in the control and
control-other groups received an information sheet and verbal instructions
from the researcher and completed the questionnaires in their homes and
returned them via reply paid mail. Rate of return of questionnaires from par-
ticipants in the TBI and control groups was 100%, with 90% of questionnaires
returned by TBI-other participants and 88% returned by control-other
participants.

Data analysis
The data were analysed using the Statistical Package for Social Sciences
(SPSS) for Windows Version 11.0. Data were screened for missing values
and collapsed from four categories (strongly disagree, disagree, agree,
strongly agree) into two categories (disagree and agree) to increase the stat-
istical power by increasing the number of responses within each category.
Non-parametric tests were used for all analyses given the categorical nature
of the data. An alpha level of .5 was chosen. The results that were significant
at p , .05 may be a result of a Type I error given the multiple comparisons in
the study. However, due to the exploratory nature of this study, the alpha level
was not adjusted.
A series of analyses of section C of the CAPM were conducted. The data
analysis consisted of (1) the Wilcoxon Signed Ranks Test to compare the TBI
self-ratings and TBI-other ratings, (2) the Wilcoxon Signed Ranks Test to
compare the control group’s self-ratings and the control-other ratings, (3)
the Mann-Whitney U Test to compare the TBI group and the control group
self-ratings, (4) the Mann-Whitney U test to compare the TBI-other ratings
 PROSPECTIVE MEMORY IN ADULTS WITH TBI 323

and the control-other ratings, and (5) the Wilcoxon Signed Ranks Test to
compare questions addressing the same aspect of Ellis’ theory to determine
whether the questions were sensitive in discriminating the different errors
that can occur within each of the phases, based on other factors that influence
prospective memory (e.g., source of the intention). For example, “I frequently
forget to do things that other people have asked me to do” and “I frequently
forget to do things that I have planned to do” both address phase (a) or
the formation and encoding of the intended action but they ask about different
conditions in this phase, that is, variation in the source of the intention (i.e., a
self-initiated intention versus an externally-initiated intention). The questions
selected for comparison were chosen on the basis of a priori analysis. The
matched questions are 1 and 2, 3 and 4, 5 and 6, 8 and 9, and 13 and 14.
Questions 10, 11 and 12 all address the retention interval. Statistical compari-
sons using the Wilcoxon Signed Ranks Test were conducted between each of
the possible paired questions within the set of three (10 and 11, 10 and 12, and
11 and 12). The data were reversed in questions 8 and 10 because of the
opposite direction of questioning. Also, to reduce the number of comparisons
for matched questions of analyses addressing each of the phases of prospec-
tive memory, only significant others’ reports were analysed, given these were
considered a more accurate picture of the function of people with TBI than
self-reports.

RESULTS
Using the Wilcoxon Signed Ranks Test there were significant differences
between the TBI group and TBI-other for questions 8 (p ¼ .05) and 9
( p ¼ .02). The TBI-others reported that the TBI group had higher reliance
on others to facilitate prospective memory than was self-reported by the
TBI group. Similarly, the TBI-others reported a higher reliance on external
aids to facilitate prospective memory than was self-reported by the TBI
group. See Table 2.
There was a significant difference between control group’s self-ratings and
control-other’s ratings on question 2 ( p ¼ .01). In comparison to control-
other reports, the control group agreed significantly more that, when they
forgot to do something they had planned to do, it was usually because they
forgot what they had to do.
Mann-Whitney U tests between the TBI group and control group found no
significant differences, indicating that the two groups reported very similar
agreement levels for reasons for prospective remembering and forgetting
(Table 3).
In Table 4, the Mann-Whitney U Test between the TBI-other and control-
other groups found significant differences on questions 4, 6, 8, 9, and 13.
324 ROCHE ET AL.

TABLE 2
Comparison of “agree” response rates from the TBI group and TBI-
other on section C of the CAPM

% Agree

Question Participant Significant others Z p

1 65.8 47.1 21.41 .16

2 73.7 52.9 21.50 .13
3 42.1 50.0 21.07 .29
4 34.2 32.4 20.26 .80
5 94.7 97.1 20.58 .56
6 84.2 67.6 21.39 .17
7 68.4 61.8 20.71 .48
8 50.0 29.4 22.00 .05
9 42.1 23.5 22.33 .02
10 15.8 8.8 20.71 .48
11 76.3 70.6 20.82 .41
12 78.9 76.5 20.38 .71
13 73.7 79.4 20.58 .56
14 71.7 73.5 20.71 .48
15 36.8 47.1 20.54 .59


p , .05, two-tailed.

TABLE 3
Comparison of “agree” response rates from the TBI group and control
group on section C of the CAPM

% Agree

Question TBI Control Z p

1 65.8 47.1 21.59 .11

2 73.7 64.7 20.82 .41
3 42.1 35.3 20.59 .56
4 34.2 20.6 21.28 .21
5 94.7 97.1 20.49 .63
6 84.2 94.1 21.33 .19
7 68.4 52.9 21.34 .18
8 50.0 70.6 21.77 .08
9 42.1 47.1 20.42 .68
10 15.8 2.9 21.82 .07
11 76.3 61.8 21.33 .18
12 78.9 70.6 20.81 .42
13 73.7 52.9 21.82 .07
14 71.7 55.9 21.33 .18
15 36.8 47.1 20.87 .38
 PROSPECTIVE MEMORY IN ADULTS WITH TBI 325

TABLE 4
Comparison of “agree” response rates from the TBI-other and control-
other groups on section C of the CAPM

% Agree

Question TBI-other Control-other Z p

1 47.1 46.7 20.03 .98

2 52.9 36.7 21.30 .20
3 50.0 26.7 21.89 .06
4 32.4 6.7 22.53 .01
5 97.1 96.7 20.09 .93
6 67.6 90.0 22.14 .03
7 61.8 46.7 21.20 .23
8 29.4 56.7 22.19 .03
9 23.5 63.3 23.19 .00
10 8.8 10.0 20.16 .87
11 70.6 66.7 20.34 .74
12 76.5 73.3 20.29 .77
13 79.4 56.7 21.94 .05
14 73.5 70.0 20.31 .76
15 47.1 60.0 21.03 .30


p , .05, two-tailed;  p , .01, two-tailed.

These differences were in the direction of the TBI-others agreeing signifi-

cantly more than the control-others that their relatives forgot planned activi-
ties (question 4) and needed memory aids (question 9). The TBI-others also
agreed significantly more than control-others that their relatives relied on
others to remind them to do things (question 8) and had difficulty remember-
ing when they were engrossed in other tasks (question 13). The control-others
agreed significantly more than the TBI-others that their relatives remembered
activities that are important for other people (question 6).
Significant differences between matched questions that address different
phases and variables within Ellis’ model were identified using the Wilcoxon
Signed Ranks Test using ratings by the TBI-other group for matched pairs 3
and 4, 5 and 6, 10 and 11, and 10 and 12 (Table 5). There was a significant
difference between paired questions 3 and 4 which address the source of
information (self or others) in the formation and encoding of intentions.
According to the TBI-others, the TBI group forgot other people’s requests
significantly more than they forgot activities that they had planned to do
themselves. Questions 5 and 6 indicated significant differences between the
source of motivation (important for self or important for others) in the for-
mation and encoding of intentions. According to the TBI-others, the TBI
group was more likely to remember a prospective memory task if it
326 ROCHE ET AL.

TABLE 5
Comparison of “agree” response rates by TBI-others on paired questions in section C of
the CAPM addressing the same aspects in Ellis’ model

Question number
Stage of Ellis’ model (what is being addressed) % Agree Z p

Encoding 1 (when) 47.1

2 (what) 52.9 20.43 .67
3 (source-others) 50.0
4 (source-self) 32.4 22.12 .03
5 (motivation-self) 97.1
6 (motivation-other) 67.6 23.16 .00
8 (reminders from others) 29.4
9 (reliance on external aids) 23.5 20.58 .56
Retention interval 10 (immediate future) 8.8
11 (long delay) 70.6 24.58 .00
10 (immediate future) 8.8
12 (multiple tasks before 76.5 24.80 .00
prospective memory task)
11 (long delay) 70.6
12 (multiple tasks before 76.5 21.00 .32
prospective memory tasks)
Performance interval, initiation 13 (engrossed in other task) 79.4
and execution of intended actions 14 (disruption) 73.5 20.71 .48


p , .05, two-tailed;  p , .01, two-tailed.

was important to them compared to a task that was important to another

person.
There was also a significant difference between questions 10 and 11, which
refer to timing in the retention interval (immediate or long delay). According
to the TBI-others, the TBI group was highly likely to remember a prospective
memory task if it was to be performed in the immediate future and unlikely to
remember if there was a long delay before task performance. There was also a
significant difference between responses to questions 10 and 12. According to
the TBI-others, the TBI group would be more likely to forget to perform a
task if there were multiple other tasks to do during the retention interval,
than if they had to perform a task in the immediate future.
A similar analysis of the different phases and variables within Ellis’ model
was conducted on the data from control-other group (see Table 6). Significant
differences were found only for matched pairs 10 and 11 ( p ¼ .00), and 10
and 12 ( p ¼ .00). According to the control-others, the control group was
more likely to remember a prospective memory task if it was to be performed
in the immediate future than if there was a long delay or multiple other tasks
to complete before the task was to be performed.
 PROSPECTIVE MEMORY IN ADULTS WITH TBI 327

TABLE 6
Comparison of “agree” response rates by control-others on paired questions in section C
of the CAPM addressing the same aspects in Ellis’ model

Question number
Stage of Ellis’ model (what is being addressed) % Agree Z .p

Encoding 1 (when) 46.7

2 (what) 36.7 20.69 .49
3 (source-others) 26.7
4 (source-self) 6.7 21.90 .06
5 (motivation-self) 96.7
6 (motivation-other) 90.0 21.00 .32
8 (reminders from others) 56.7
9 (reliance on external aids) 63.3 20.54 .59
Retention interval 10 (immediate future) 10.0
11 (long delay) 66.7 24.12 .00
10 (immediate future) 10.0
12 (multiple tasks before 73.3 24.15 .00
prospective memory task)
11 (long delay) 66.7
12 (multiple tasks before 73.3 20.82 .41
prospective memory tasks)
Performance interval, initiation 13 (engrossed in other task) 56.7
and execution of intended actions 14 (disruption) 70.0 21.63 .10


p , .01, two-tailed.

DISCUSSION
The aim of this study was to investigate the reasons underlying reported pro-
spective memory failure in adults with TBI with reference to the stages in
Ellis’ model, from the perspective of individuals with TBI and their signifi-
cant others. According to responses of significant others, individuals with
TBI were more likely than controls to (1) forget planned activities, (2)
forget to do things when engrossed in other tasks, (3) forget to do things
that are important to other people, (4) need memory aids, and (5) rely on
others to remind them to do things.
The first objective was to compare self-ratings of the TBI and control
groups with ratings by their significant others to discover differences in
their responses to the questionnaire. It was hypothesised that there would
be higher agreement between the control and control-other group than
between the TBI and TBI-other group. This hypothesis was only partially
supported, since only 2 out of 15 differences were significant for the TBI
group compared to 1 out of 15 for controls.
Specifically, the control group reported significantly more than the control-
others that their prospective memory failures were usually because they
328 ROCHE ET AL.

forgot what they had to do. Observer bias of the significant other might
account for this difference. It is difficult for significant others to predict the
source of memory failure because the source is not explicit when memory
failure occurs. For example, when people forget what they had to do, it is unli-
kely that they would specify to their significant others whether they forgot
what they had to do or when they had to do it. Therefore significant others
might not be able to accurately attribute the source or the reason behind
the participants’ prospective memory failure.
The TBI-others reported that the TBI group was more reliant on others and
on external aids to facilitate prospective memory than self-reported by the
TBI group. Increased need for external aids and other people to facilitate pro-
spective memory addresses the variable of encoding or the formation of pro-
spective memory in Ellis’ model (1996). A possible explanation for this
discrepancy in reporting is that people with TBI have impaired self-awareness
of their prospective memory problems, such that at the point of encoding and/
or thereafter, they neither realise nor testify to their real need for external
memory aids or other people to help them prospectively remember. An
alternative explanation is that people with TBI are not only forgetful, but
they may indeed forget that they are forgetful, thus leading to the inability
to accurately report on their reliance on external aids and other people for
reminders (cf. the “memory introspection paradox”, Herrmann, 1982).
The second objective of this study was to compare the TBI group and
control group on reported reasons for remembering and forgetting. The
hypothesis that there would be no significant differences between the TBI
and control groups in their prospective memory self-ratings was supported,
with no significant differences found between the groups on responses in
section C of the CAPM. This is consistent with the findings from the previous
study on the same sample investigating responses about the frequency of pro-
spective memory failure (section A of the CAPM), which indicated that the
TBI group reported similar prospective memory ability to controls (Roche
et al., 2002). The finding might be due to persons with brain injury reporting
pre-morbid levels of functioning. Other studies indicate that brain injured
individuals tend to overstate their abilities (Fleming & Strong, 1999; Priga-
tano, 1996). Alternatively, the finding could suggest, that the control group
understated their ability, especially given the high rate of agreement
between the TBI group and TBI-other.
It was hypothesised that there would be a significant difference between
the responses of the TBI-other and control-other groups. This hypothesis
was supported by significant differences on five items. The TBI-others
reported that the reasons for prospective forgetting included difficulties in
the encoding phase and the performance interval and execution of intended
actions according to Ellis’ model (1996). According to significant others,
the TBI group forgot activities that they had planned themselves more than
 PROSPECTIVE MEMORY IN ADULTS WITH TBI 329

the control group. With reference to Ellis’ model, this item was designed to
address the source (self or others) of the prospective memory task in the for-
mation and encoding of intentions phase. This finding therefore suggests that
individuals with TBI have prospective memory problems even when the for-
mation and encoding of the intention is self-initiated.
The TBI group also relied on memory aids and other people for reminders
more than the control group, according to their significant others. This is not
an unusual finding as the reliance of people with TBI on prompts is com-
monly seen in the clinical setting. According to Ellis’ model (1996), using
a memory aid such as a notebook or diary assists in the encoding of the
memory. A person must accurately record the information in the encoding
phase in order for it to be successfully utilised at a later point in time. Reliance
on others for reminding requires that the individual requests of another
person, in the encoding phase, to remind him or her. Thus, these findings
address actions and support that occur during the phase of formation and
encoding of prospective memories.
Significant others also reported that, compared to the TBI group, the
control group was more likely to remember activities that were important
for other people. Although this difference was significant ( p ¼ .03), the
majority of TBI-others (84%) and control-others (94%) agreed that the indi-
viduals in the TBI and control groups did remember tasks that were important
to others. For the small group of individuals with TBI who were perceived
more likely to forget tasks that were important to others, this may be inter-
preted as related to motivation in Ellis’ formation and encoding phase.
Lapses in prospective memory when engrossed in another task were
reported by significant others as being more of a problem for the TBI
group than the control group. With reference to Ellis’ model, this difficulty
can be understood as an error in either the performance interval or at the
initiation and execution of the prospective memory tasks. Ellis’ (1996)
model explains that the success of prospective remembering can be affected
by distractions. Problems with distractions can occur either during or prior to
the event and can be either internal or external in origin. This finding indicates
that interaction with another task provides a distraction and impedes the
initiation of the prospective memory task for individuals with TBI.
It is interesting to note that some of the differences in reasons for prospec-
tive forgetting identified by the TBI-other and control-other groups are
similar in nature to executive function deficits. For example, the difficulty
that individuals with TBI have in initiating an encoded intention could be
related to one type of executive function deficit, namely, problem in initiating
action. As another example, the failure of individuals with TBI in remember-
ing to carry out an intended action because they were engrossed in another
task could be related to other types of executive function deficits such as a
reduction in working memory capacity or problems in alternating/switching
330 ROCHE ET AL.

between two or more tasks. This is not surprising given that the executive
function deficits resulting from damage to the prefrontal lobes are commonly
found in individuals with TBI. It would be interesting to corroborate this
relationship between prospective memory failure and executive function in
future research.
The final objective was to analyse patterns of perceived reasons for pro-
spective remembering and forgetting, with reference to the phases and vari-
ables presented by Ellis, with the TBI and control groups. Significant
others reported that the TBI group and control group tended to remember pro-
spective memory tasks that were performed in the immediate future and were
unlikely to remember if there was a long delay before the prospective
memory task was to be performed. This suggests that the length of the reten-
tion interval, explained by Ellis’ model (1996), has an impact on successful
remembering not only for individuals with TBI, but also for the general popu-
lation. A similar finding was that both the TBI group and the control group
reported higher rates of agreement for forgetting prospective memory tasks
if many other activities took place before the prospective memory task, com-
pared to performing the prospective memory task in the immediate future.
This finding also addresses the retention interval in Ellis’ model, further sup-
porting that difficulties in the retention interval are reported by people with
and without TBI.
A discrepancy was found between the TBI group and the control group in
relation to the source of information (self or others) and the source of motiv-
ation (important for self or important for others). Both variables are associ-
ated with the phase of encoding and formation of intentions in Ellis’
theory. Individuals with TBI are perceived as being more motivated to
carry out a prospective memory task when they benefit from it, or were the
source of the intention. This may be due to decreased attention to other
people’s needs. The finding suggests that individuals with TBI tend to
remember prospective memory tasks that are egocentric in nature better
than tasks that relate to others.

Implications
In this study, persons with TBI were reported as having difficulty with the
encoding and formation and initiation of prospective memories. External
aids have been found to be useful in individuals with TBI experiencing fre-
quent memory failure (Fleming, Shum, Strong, & Lightbody, 2005; Hart,
Hawkey, & Whyte, 2002; Van den Broek et al., 2000). Questions in the
CAPM section C only address memory aids to facilitate the encoding
process. However, there are various memory aids that can cue the individual
at the performance interval and execution of intended actions. A benefit of
external memory aids is that they can be personalised according to when
 PROSPECTIVE MEMORY IN ADULTS WITH TBI 331

memory failure occurs (encoding or performance interval and the execution

of intended action). For example, if individuals are identified to struggle to
initiate actions, then they can use an electronic alarm to prompt them to
remember to perform the action. However, if they have difficulty recalling
what needs to be done, then they would benefit from the use of a diary or
reviewing a list throughout the day as needed (Fleming et al., 2005; Glisky,
1996).
A further implication of this study is that the success of external aids in
benefiting individuals with TBI is also dependent on their perceived need
to rely on external aids and perceived benefit of the use of external aids.
This indicates that therapists should consider lack of self-awareness when
utilising any memory strategy with individuals with TBI.

Limitations of this study

In order to increase the power of the findings, the data were collapsed from
four into two categories in this study. Due to the nature of the sample non-
parametric tests were required. Future research should be developed such
that more robust tests can be used and with larger sample sizes. The
current study did not include experimental measures of prospective
memory, however this would be a valuable inclusion in future studies. Neu-
ropsychological assessment, such as tests of retrospective memory, would
also be a useful in order to look for subgroup differences that may lead to dis-
crepancies in prospective memory performance.
The CAPM section C has been successfully used to discriminate reasons
for successful remembering and forgetting between age groups (Waugh,
1999). However, until the current study, it has never been used with a brain
injured population. Some participants indicated that they had difficulty under-
standing a number of the questions in section C of CAPM. This might be a
result of the complexity of Ellis’ model, and the concise questioning necess-
ary to discriminate between phases and variables in the theory. Therefore it is
recommended that future studies attempt to validate the CAPM with a TBI
population, by increasing sample size and the number of items addressing
the same variables and phases in Ellis’ model, so that internal consistency
can be obtained. It would also be recommended that the validity of the
CAPM be measured against well-established prospective memory tests,
such as the CAMPROMPT.
Individuals with TBI in this study ranged from 13 weeks to 169 weeks
post-injury. Research has indicated that awareness of deficits increases with
time for brain injured individuals (Fleming & Strong, 1999). Therefore, it
would be interesting to conduct studies with groups of people with TBI
who represent different times post-injury, and in conjunction with a self-
awareness measure such as the Self-Awareness Disability Interview (SADI;
332 ROCHE ET AL.

Fleming, Strong, & Ashton, 1996), to discover the influence of awareness on

the phases of prospective remembering, as described by Ellis (1996). Further,
the effect of different prospective memory interventions on improving pro-
spective memory function at different times post-TBI and in relation to
Ellis’ phases could be investigated.

CONCLUSION
The current study aimed to investigate perceived reasons underlying prospec-
tive remembering and forgetting in adults with TBI. Findings of this study
show that individuals with TBI are reported primarily to experience prospec-
tive memory difficulties in the encoding phase relating to the source, motiv-
ation and formation of prospective memory tasks, according to Ellis’ model
(1996). This study also indicates that difficulties in the retaining of prospec-
tive memory information in the performance interval appear not to be unique
to the brain-injured population. It is recommended that the use of external
memory aids be encouraged and aimed towards the area of difficulty (encod-
ing, performance interval or the execution of intended action).

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Manuscript received October 2005

Revised manuscript received May 2006