THE IMPACT OF mTBI ON WORD-FINDING ABILITY IN YOUNG ADULTS

By

Lori DeFazio, B.S.
East Stroudsburg University of Pennsylvania

A Thesis Submitted in Partial Fulfillment of the Requirements for the Degree of Master
of Science in Communication Sciences and Disorders to the Office of Graduate and
Extended Studies of East Stroudsburg University of Pennsylvania

August 7, 2020

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ABSTRACT
A Thesis Submitted in Partial Fulfillment of the Requirements for the Degree of Master
of Science in Communication Sciences and Disorders to the Office of Graduate and
Extended Studies of East Stroudsburg University of Pennsylvania.
Student’s Name: Lori DeFazio
Title: The Impact of mTBI on Word-Finding Ability in Young Adults
Date of Graduation: August 7, 2020
Thesis Chair: LuAnn Batson-Magnuson, Ph.D., CCC-SLP
Thesis Member: Rachel Wolf, Ph.D., CCC-SLP
Thesis Member: Akila Rajappa, Ph.D., CCC-SLP, BCS-S

Cognitive and linguistic deficits have been found to be present in individuals in
the subacute phase of mild traumatic brain injury (mTBI). The present study compared
word-finding performance between young adults without a history of mTBI and those
with a history of mTBI in the post-subacute phase of injury and examined the relationship
between the number of incidents of mTBI and word-finding performance. The Test of
Adolescent/Adult Word Finding-Second Edition, Brief Test (TAWF-2, BT) was
administered to 33 age and gender matched participants (N=17 mTBI; N=16 controls) to
assess word-finding based on timing and accuracy. Participants were divided into four
groups based on the number of mTBIs they had experienced in their lifetime from 0 to
3+. There was no significant difference in TAWF-2, BT performance for participants
with or without a history of mTBI, regardless of the number of mTBI experienced, in the
post-subacute phase of injury.

TABLE OF CONTENTS
Chapter
I.

INTRODUCTION…………………………………………………………….1
Mild Traumatic Brain Injury (mTBI)………………………………………....1
Cognitive Impacts of mTBI……………………………………………….......2
Language Impacts of mTBI……………………………………………….…..3
Word-Finding Deficits..………………………………………………….........3

II.

LITERATURE REVIEW……………………………………………………..5
Current Study………………………………………………………………...11

III.

METHOD……………………………………………………………………12
Participants…………………………………………………………………...12
Word-Finding Assessment...............................................................................12
Reliability of TAWF-2, BT……………………………………………….….13
Validity of TAWF-2, BT……………………...………………….………….14
Procedure.........................................................................................................15

IV.

RESULTS……………………………………………………………………17
Participant Description…………………………………………………….…17
Research Question 1: TAWF-2, BT Performance mTBI vs Control………...18
Research Question 2: TAWF-2, BT Performance Frequency of Incident…...19

V.

DISCUSSION………………………………………………………………..20
Implications…………………………………………………………………..20
Limitations…………………………………………………………………...23
Future Directions…………………………………………………………….24
iv

Conclusion…………………………………………………………………...24
References………………………………………………………………………………..26
Appendix A: Institutional Review Board Approval……………...……………………...31
Appendix B: Consent Form…...…………………………………………………………32
Appendix C: Case History Form…………………………………………………………34
Appendix D: Concussion Symptom Inventory…………………………………………..35
Appendix E: Fidelity Procedures………………………………………………………...36

v

LIST OF TABLES
Table
1. Prevalence of mTBI……………………………………………………….….….17
2. Frequency of Descriptive Ratings……………………………………….….…....18

vi

CHAPTER I:
INTRODUCTION
Mild Traumatic Brain Injury (mTBI)
Traumatic brain injury (TBI) is a serious, acquired injury that results in damage to
the brain’s normal function. TBI may occur if the head experiences a sudden, intense
collision with an object or if an object penetrates the skull and brain tissue. Causes of TBI
include falls, motor vehicle accidents, and sport- or recreational-related accidents
(Centers for Disease Control and Prevention, 2019). There are approximately 2.8 million
new cases of TBI in the United States each year. It is estimated that 5.3 million
individuals live with a TBI-related disability in the United States (Centers for Disease
Control and Prevention, 2015). TBI can be characterized as mild, moderate, or severe,
depending on the degree of the symptoms. Nearly 75% of TBIs that occur each year are
mild (Centers for Disease Control and Prevention, 2003). An individual that has suffered
from a mild TBI (mTBI), commonly referred to as a concussion, may remain conscious
or experience a brief loss of consciousness for several seconds or minutes. Symptoms of
mTBI include headache, confusion, nausea, dizziness, blurred vision, sensitivity to light

1

and/or noise, fatigue or drowsiness, changes in sleep patterns, changes in mood or
behavior, and difficulty with memory, concentration, or thinking (Centers for Disease
Control and Prevention, 2019). Recovery phases of mTBI symptoms are hyperacute,
occurring within one hour of injury (Ganti et al., 2014), acute, manifesting hours to days
following injury, and subacute, occurring weeks post-injury (Mayer et al., 2017).
Cognitive Impacts of mTBI
Many individuals with a history of a single mTBI will continue to demonstrate
significant impairment in various cognitive areas including executive function, memory,
attention, and processing speed long after the initial injury (McInnes et al., 2017).
Episodic memory and executive processes associated with encoding, storage, and
retrieval, together with strategy formulation, have been found to be the main altered
cognitive functions in individuals with a history of a single mild to moderate TBI more
than one-year post-injury (Miotto et al., 2010). On the other hand, multiple mTBIs can
result in cumulative damage to an individual’s brain. This can be identified through
electrophysiological measures, such as event-related potentials, of brain function (Gaetz
et al., 2000). Multiple mTBIs are associated with more severe symptoms than single
incident mTBIs and slower recovery of neurological function after subsequent incidents
(Centers for Disease Control and Prevention, 1997; Covassin et al., 2013; Guskiewicz et
al., 2003; Institute of Medicine and National Research Council, 2014; Slobounov et al.,
2007). Individuals with a history of multiple mTBIs demonstrate worse performance on
neuropsychological tests, in the areas of attention, visual memory, and working memory,
than those with a history of a single mTBI. Individuals in the acute phase of recovery
with a history of three or more mTBIs take longer to recover verbal memory and have
2

slower reaction times than those with a history of one or no previous mTBI (Covassin et
al., 2013). Enduring effects of mTBI, such as mild reductions in attention and mental
processing speed and persistent symptoms similar to individuals in the acute phase of
mTBI recovery, have been documented in young adults with multiple incidences of
mTBIs who are no longer in the acute phase of recovery (Moser & Schatz, 2001).
Language Impacts of mTBI
The frontal and temporal lobes of the brain are involved in encoding, storage,
retrieval of information, and information processing speed. Right and left frontaltemporal and left parietal-occipital lesions due to history of a single mild-to-moderate
TBI may result in impaired word-finding, nominal verbal fluency, and reduced
information processing speed (Miotto et al., 2010). Language deficits may reveal an
interaction with reduced cognitive abilities (Stockbridge & Newman, 2019). Individuals
that have suffered from one or more mTBIs demonstrate reduced mental processing
speed, which likely plays a role in cognitive-linguistic performance (Stockbridge &
Newman, 2019; Norman et al., 2019). Adequate mental processing speed is critical for
daily language tasks, such as word-finding, which contributes to conversational success
(Norman et al., 2019).
Word-Finding Deficits
Impaired word-finding is a frequently reported language deficit resulting from mTBI
(King et al., 2006; 2006). Word-finding is defined as the “process of finding the correct
terminology for an object, picture, orthographic representation, or conversation in which
a person converts the initial conception to a lexical version” (Walker et al., 2006). Wordfinding difficulties may be described by a variety of terms, such as problems getting
3

words out, using jumbled words, complaints of a reduced vocabulary, frequently
experiencing tip-of-the-tongue phenomenon, or overlapping difficulties with wordfinding and message-planning in conversations, all of which could indicate a general
deficit in accessing stored lexical representations (Popescu et al., 2017). Individuals that
have suffered from a single moderate or severe TBI demonstrate reduced efficiency in the
ability to access feature information in the subacute phase of recovery, despite the
presence of intact semantic knowledge, but this is not specific to mild forms
(McWilliams & Schmitter-Edgecombe, 2008). The inability to access and integrate
features may interfere with activation of a semantic memory and its associated word
representation due to multiple incidents of mTBI (Fratantoni et al., 2017). Previous
research has revealed that individuals in the subacute phase of single and multiple
incidents of mTBI exhibit lower accuracy rates during completion of word-finding tasks
(Norman et al., 2019).
Efficient word-finding is necessary for performance of activities of daily living,
and even mild deficits can impair communication in the work environment, academic
setting, and during social interactions (Fratantoni et al., 2017). According to data from
the Colorado TBI registry, which includes all individuals hospitalized with TBI in that
state, approximately 50% of those who suffered from a severe TBI failed to return to
work at one-year post injury, and 20% of those who suffered from mTBI were
unemployed (Whiteneck et al., 2001). Therefore, many individuals with a history of
mTBI who may struggle with word-finding, an important skill for most high-level tasks
in the workplace, may experience the negative effects of this deficit in their daily lives.

4

CHAPTER II:
LITERATURE REVIEW
The purpose of this literature review is to provide an overview of the existing
body of literature regarding the impact of mTBI on word-finding ability in young adults
in the post-subacute stage of recovery. A search was conducted of the following
EBSCOhost databases: Academic Search Ultimate, Google Scholar, Journal of the
American Medical Association (JAMA), MEDLINE Complete, PubMed, and Psychology
and Behavioral Sciences Collection. Inclusion criteria required that studies be empirical
and peer-reviewed, utilize individuals 18-24 years of age with a history of single or
multiple mTBIs, and evaluate word-finding ability in the subacute or post-subacute phase
of recovery. Five journal articles met these criteria, and 27 did not meet these criteria.
The following search terms were used: mTBI, brain injury, concussion, word-finding,
word retrieval, naming.
Barrow et al. (2006) investigated confrontation-naming latency and accuracy
using pictures. Participants included 24 adults 18-53 years of age with mTBI examined
within one-week post-injury and 24 age matched controls. Participants were presented

5

with 72-line drawings that were divided into three sets of 24 pictures to correspond to a
picture vocabulary age of 3 years or below, 4-7 years of age, and 18 years or older. The
picture stimuli were presented on a computer with prompts given to the participant to
attend to the stimulus. Participants were asked to speak the name of the pictures as
quickly as possible. The task examined latency and accuracy for word-finding ability
under speeded conditions. A three-factor mixed analysis of variance (ANOVA), with one
between and two within subject variables, was conducted to determine the effects of
vocabulary level, category, and group on naming latency. The analysis revealed that the
mTBI group demonstrated significantly slower response latencies than the control group
(F(1, 46) = 11.90, p < 0.001), and both groups demonstrated slower response latencies as
vocabulary level increased (F(2, 92) = 103.50, p < 0.001). A three-factor mixed ANOVA,
with one between subject and two within-subject variables, was conducted to investigate
the effect of vocabulary level, category and mTBI on picture naming accuracy. The
analysis revealed statistically significant main effects of group (F(1, 46) = 11.10, p =
0.002), vocabulary level (F(2, 92) = 20.65, p < 0.001) and category (F(1, 46) = 6.99, p =
0.011). A significant two-way interaction of vocabulary level by group (F(2, 92) = 3.27, p
= 0.043) was found. The mTBI group exhibited significantly more difficulty with naming
and had even greater difficulty than the control group as vocabulary level increased.
Norman, Shah, and Turkstra (2019) studied reaction times and error rates on a
category-naming task. Twenty adults with mTBI ages 18-55 were compared to age- and
education-matched adults with orthopedic injury (OI). Participants were tested in the subacute phase of recovery, 3–12 weeks post-injury. Participants viewed 120 pictures and
named one other item belonging to the same category as the picture in view. Pictures
6

were presented in speeded and unspeeded conditions. The picture stimuli were
manipulated by presentation time, stimulus category, and vocabulary difficulty. It was
hypothesized that participants in the mTBI group would demonstrate longer response
times and a greater number of errors than those in the OI group when given a categorynaming task. Repeated measures ANOVA with main effects of group and condition on
response time and overall accuracy were performed. Results revealed a significant effect
of condition on response time for both groups (F (1,39) = 58.05, p = .00, η2 = .04), where
speeded conditions had faster response times and more errors than the unspeeded
conditions. Regarding accuracy, participants in the mTBI group had significantly more
errors than participants in the OI group (F (1,39) =1.75, p = .09, η2 = .04). Participants
with mTBI demonstrated more errors than the OI group in both speeded and unspeeded
conditions, but this difference was not statistically significant. In both groups, most errors
occurred in the unspeeded condition.
Stockbridge and Newman (2019) examined narrative performance and discrete
cognitive-linguistic skills in isolation in those who had experienced one or more mTBIs.
The study included a total of 81 participants ages 12-40 years old, including 58
individuals with a history of at least one mTBI (most recent was nearly 5 years previous)
and 23 individuals without a history of mTBI. Those with a history of mTBI reported an
average of 3 mTBIs in their lifetime. Participants completed language and cognitive tasks
and surveys online. They were asked to produce two written narrative samples: a retelling
of Cinderella (supplemented by pictures of key events) and a retelling of a short video
titled “Pigeon: Impossible” immediately after watching it. The narrative samples were
analyzed for general all-purpose (GAP) verbs that could have indicated underlying
7

language deficits. It was hypothesized that individuals with a history of mTBI would
show deficits in complex writing. Participants with a history of mTBI had difficulty
providing key content when presented with a novel video and asked to provide a
summary. Individuals with a history of mTBI used a greater proportion of GAP verbs
than individuals without a history of mTBI, which approached significance based on an
independent-samples t-test, t(77) = 1.85, p = .07 (two-tailed). This finding indicates that
these individuals may have been experiencing word-finding difficulties, since GAP verbs
are non-specific high-frequency words. During a confrontation naming task, participants
read a series of 20 definitions and provided the word that best fit the definition as quickly
as possible. Results indicated that individuals with a history of mTBI performed similarly
to individuals with no mTBI on tasks that targeted this single skill. These findings
suggest that individuals with a history of multiple mTBIs may continue to experience
deficits in cognitive and linguistic skills required for written narratives long after injury.
However, no significant difference was found in naming abilities between the two
groups.
King et al. (2006) examined the differences in standard scores and error types
during word-finding in naming and discourse tasks. Ten participants with mTBI and 10
age, gender, and education matched controls (Age mean = 28.813, SD = 8.138) were
included in the study. Participants with mTBI were tested in the acute phase of recovery,
ranging from 2 to 14 days post-injury. All participants were administered the Test of
Word Finding in Discourse (TWFD; German, 1991) and a computerized version of the
Test of Adolescent/Adult Word-Finding (TAWF; German, 1990). The TAWF assesses
word-finding skills in various contexts, and the TWFD consists of three pictures that are
8

presented in order to obtain a narrative discourse sample. Data was analyzed between
both groups on the TAWF and TWFD using a repeated measures ANOVA. Additionally,
an independent samples t-test was performed to measure the significance of latency as an
error type in word-finding. Results indicated that three participants for each task
demonstrated psychometrically-based word-finding deficits with standard scores of less
than 85. A significant difference was found between the two groups in the mean standard
scores for the TAWF (F(1, 18) = 13.252; p = 0.002) indicating that the mTBI group
performed significantly worse than the control group regarding accuracy. Results of an
independent-samples t-test revealed a significant group difference on the TAWF
regarding the occurrence of latency errors based on total words produced (t = 2.337, p =
0.03), indicating that the MTBI group demonstrated overall slower responses than the
control group. There were no significant differences between groups for the measures
from the TWFD. Greater word-finding errors occurred for the TAWF than the TWFD,
revealing latency as the most common error.
King et al. (2006) investigated differences in accuracy and response time for noun
and verb naming in individuals with a history of mTBI using the TAWF as the
experimental task. Ten participants with a history of mTBI and 10 non-brain damaged
(NBD) participants between the ages of 18 and 45 years old were age, gender, and
education matched. Inclusion criteria included normal vision and hearing and no history
of developmental disabilities, previous head injury, or substance abuse. Time post-injury
ranged from 4 to 37 days (mean = 15.6). Visual and auditory stimuli from the subtests of
the TAWF were presented via laptop computer in order to ensure that all participants
received the same conditions. A one-tailed independent sample t-test was performed to
9

determine if there was a difference in accuracy between noun and verb naming. Results
revealed a significant difference between the mTBI group and the NBD group in noun
naming (t = 2.593, p = .018), indicating that the mTBI group was less accurate than the
NBD group. There was no significant difference between the groups in accuracy for
naming verbs. One-tailed independent sample t-tests were performed to determine
response time differences for each of the TAWF subtests between groups. Results
indicated significant group differences for all subtests (Noun1 t = 2.571, p = .009; Noun2
t = 1.976, p = .032; Noun3 t = 1.935, p = .034; Noun4 t = 2.812, p = .006; and Verb t =
3.680, p = .001), with the NBD group exhibiting faster response times on all subtests. In
addition, there was a significant group difference when all noun subtests were combined
(t = 2.708, p = .007), indicating that response times for the NBD group on the noun
naming tasks was significantly faster than the mTBI group.
This literature review reveals that four studies provide evidence that word-finding
deficits are experienced by individuals with a history of mTBI when compared to
individuals without a history of mTBI. Of these studies, two looked at the subacute phase
of recovery and two looked at the acute phase of recovery. A single study conducted
during the post-subacute phase of recovery indicated that differences in word-finding
performance were not observed. All studies took place less than 12 weeks post-injury.
Most studies reviewed included a small number of subjects and a wide range of ages in
the subject population. A single study clustered 40-year-old adults with children as young
as 12-years-old in their subject population.
Overall, the studies reviewed were conducted with a small number of subjects and
included a broad range of ages as well as varied in the phase of recovery when subjects
10

were assessed. Inconsistencies in findings, a lack of studies examining the impact of
multiple mTBIs, and a lack of studies focusing on the presence of word-finding deficits
in young adults in the post-subacute phase (6 months or greater post-injury) of recovery
support the need for additional research in this area. Long term deficits in word-finding
can result in extreme social distress due to the inability to maintain previous levels of
performance at work and participation in life (King et al., 2006).
Current Study
The goal of this study is to look more closely at word-finding performance in
young adults with a history of mTBI in the post-subacute phase (6 months or greater
post-injury) of recovery, to determine the presence or absence of word-finding deficits,
and to determine the impact of single vs multiple mTBIs.
The current study aims to answer the following questions:
a. Do subjects with a history of mTBI demonstrate significantly lower wordfinding performance on the TAWF-2, BT than controls?
b. Does word-finding performance correlate with reported number of mTBI?

11

CHAPTER III:
METHOD
Participants
Participants included college students enrolled at the local university and
individuals from the surrounding areas. Participants were recruited via university public
relations dissemination of flyers through university listserv, Facebook, Instagram, and
Twitter, or referred by word of mouth. All participants met the following inclusion
criteria: 18-24 years of age, with or without a history of mTBI, in the post-subacute phase
of recovery (6 months or greater post-injury), without hearing or vision loss, and without
a history of learning disability, language impairment, or speech or language therapy
services per self-report.
Word-Finding Assessment
The Test of Adolescent/Adult Word Finding-Second Edition Brief Test (TAWF2, BT) (German, 2016) was administered to all participants to assess word finding ability
based on timing and accuracy. The TAWF-2, BT is a norm-referenced, single-word
expressive language test specifically designed to assess the word-finding ability of
adolescents and adults. It is used by speech-language pathologists to identify individuals
12

who have word-finding problems, plan word finding intervention, and measure word
finding ability in research studies. The TAWF-2, BT consists of 28 items chosen from the
Complete Test organized into four naming sections: (1) Picture Naming: Nouns, which
assesses efficiency in naming target words (2) Sentence Completion Naming, which
assesses efficiency in naming words to complete sentences read aloud by the examiner
(3) Picture Naming: Verbs, which assesses efficiency in naming present and past-tense
regular and irregular verbs and (4) Picture Naming: Word Groups, which assesses
efficiency in naming nouns in semantic and phonemic word groups. The normative
sample included 1,710 individuals 12:0–80:11 years of age from 28 states. The
characteristics considered and represented in the normative sample include gender,
chronological age, geographic region (USA), educational level, race, Hispanic status,
exceptionality status, and household income.
Reliability of TAWF-2, BT
Reliability of the TAWF-2, BT is reported in three forms: internal consistency,
test-retest, and interscorer. The test authors note that in order for a test to be considered
minimally reliable, its reliability coefficient must approach or exceed .80 in magnitude.
However, coefficients of .90 or greater are deemed most desirable. High levels of internal
consistency reliability signify that all test items measure the same construct. The internal
consistency reliability coefficient for the TAWF-2, BT across all age groups is .76.
Evidence of internal consistency reliability for specific subgroups indicates that the
coefficients all round to or exceed .80, which suggests that the TAWF-2, BT is reliable
for the seven gender, racial, and ethnic subgroups included in the normative sample. Testretest reliability is a measure of how consistent a test taker’s scores are over time. The
13

test-retest coefficient for the Word Finding Index is .94 for the TAWF-2, BT, which
demonstrates strong test-retest reliability. Interscorer reliability refers to the consistency
of scores across various examiners. The interscorer reliability coefficient for the TAWF2, BT is .99, indicating near complete agreement between examiners. These findings
indicate that the TAWF-2, BT exhibits high levels of reliability, thus, test users should
feel confident in its results (German, 2016).
Validity of TAWF-2, BT
Validity of the TAWF-2 is reported in three forms: criterion-prediction, constructidentification, and content-description. Criterion-prediction validity is described as the
test’s success in predicting an individual’s performance on specific tasks, which was
measured by comparing the TAWF-2 to well-known spoken language tests. The average
correlation of the Word Finding Index with those of other common expressive language
tests is large in magnitude. Diagnostic accuracy studies suggest that the TAWF-2, BT can
accurately identify students with word-finding difficulties, demonstrating criterionprediction validity (i.e., sensitivity = .98, specificity = .84, receiver operating
characteristic (ROC)/area under the curve (AUC) = .96, cut score = 90). Constructidentification validity relates to the degree to which the skill of word-finding can be
identified and that one dominant factor underlies the four naming subtests. Exploratory
factor analysis (EFA) of the TAWF-2’s subtest raw totals indicated that the word-finding
factor produced an eigenvalue of 2.79. All four naming subtests had substantial loadings
on the word-finding factor (i.e., Picture Naming: Nouns = .72, Sentence Completing
Naming = .65, Picture Naming: Verbs = .66, Picture Naming: Categories = .76),
indicating strong construct-identification validity. Content-description validity is
14

demonstrated through the rationale for the TAWF-2 content, formats, and target word
selection, as well as the analyses used to choose appropriate items statistically. When
choosing the TAWF-2, BT target words, the author considered semantic-taxonomic and
thematic relations, syntactic features, word comprehensibility, word frequency,
neighborhood density, neighborhood frequency, phonotactic probability, and word
length. Additional justification for the TAWF-2 content-description validity is provided
in the examiner’s manual (German, 2016).
Procedure
This study was conducted in compliance with requirements of the East
Stroudsburg University Institutional Review Board (Appendix A). All participants
received and signed an informed consent prior to participation (Appendix B). Participants
were provided with randomly selected code numbers to protect each participant’s identity
and all identifying information was stored separately. Participants were asked to complete
a brief case history form developed by the primary co-investigator and report on the
number of mTBIs experienced, causes of mTBIs, date of most recent mTBI, and selfinterpretation of word-finding ability by answering three yes/no questions regarding
presence of periodic word-finding problems (Appendix C). Participants were divided into
four groups based on the number of mTBIs they had experienced in their lifetime [0
mTBI (no history of mTBI), 1 mTBI (history of single incident mTBI), 2 mTBIs (history
of two incidents of mTBI), and 3+ mTBIs (history of three or more incidents mTBI)].
Following the case history form, all participants completed the Concussion Symptom
Inventory (CSI) (Randolph et al., 2009) and were asked to rank their current symptoms
based on how they were feeling on the day of testing. Any participant with a history of
15

mTBI that noted any of the following were excluded due to symptoms indicative of the
acute phase of mTBI: nausea, balance problems/dizziness, feeling like “in a fog”,
difficulty concentrating, sensitivity to light, sensitivity to noise, blurred vision, or feeling
slowed down (Appendix D). After completion of paperwork, a bilateral pure-tone hearing
screening following the American Speech-Language-Hearing Association (ASHA) Adult
protocol was conducted on each participant (ASHA, 2020). The TAWF-2, BT was
administered by the primary co-investigator and trained graduate students of the
Department of Communication Sciences and Disorders in therapy rooms. Participants
were informed of their right to discontinue testing at any time if they began to experience
psychological distress. Raw scores, Word Finding Index scores, and percentile scores on
the TAWF-2, BT were collected and analyzed using the standardized administration
guidelines in the examiner’s manual between subject groups (0 mTBI, 1 mTBI, 2 mTBIs,
3+ mTBIs). Examiners were blinded to which group the participant was in when
administering the TAWF-2, BT. All examiners attended training on the specific test
administration, scoring, and fidelity check procedures associated with this study. A
specific fidelity check system was used to ensure the accuracy of data collected and the
reliability and validity of the assessments (Appendix E).

16

CHAPTER IV
RESULTS
Participant Description
Seventeen participants with a history of mTBI (11 females, 6 males) and 16
participants without a history of mTBI (8 females, 8 males) were included in this study.
Ages of participants ranged from 19-24 years old. The causes of injuries reported by
participants with a history of mTBI included sport-related accidents, falls, and injuries
where the head was hit with an object. Prevalence of mTBI in the experimental group is
provided in Table 1. Time post-injury for the mTBI group was a maximum of 18 years
and a minimum of 10 months prior to testing. All participants passed bilateral pure-tone
hearing screenings following the ASHA Adult protocol (ASHA, 2020).
Table 1
Prevalence of mTBI
Number of mTBI

n

%

1
2
3 or greater
Total

5
5
7
17

29.4
29.4
41.2
100.0

Note. mTBI = mild traumatic brain injury.
17

Research Question 1: TAWF-2, BT Performance mTBI vs Control
An independent-samples t-test was conducted to compare TAWF-2, BT raw
scores between participants with and without a history of mTBI. There was no significant
difference (t(31) = 0.443, p = 0.661) in the TAWF-2, BT raw scores for participants with
a history of mTBI (M = 21.65, SD = 4.20) and participants without a history of mTBI (M
= 21.00, SD = 4.20). An independent-samples t-test was conducted to compare TAWF-2,
BT Word Finding Index between participants with and without a history of mTBI. There
was no significant difference (t(31) = 0.39, p = 0.697) in the TAWF-2, BT Word Finding
Index for participants with a history of mTBI (M = 84.65, SD = 18.01) and participants
without a history of mTBI (M = 82.65, SD = 16.96). Frequency of descriptive ratings for
participants with a history of mTBI (M = 3.18, SD = 0.287) and participants without a
history of mTBI (M = 2.81, SD = 0.319) is provided in Table 2. These results indicate
that history of mTBI does not have an effect on TAWF-2, BT raw scores and Word
Finding Index. Specifically, these results suggest that history of mTBI does not affect
word-finding ability in this subset of young adult college population.
Table 2
Frequency of Descriptive Ratings
Word Finding Descriptive Rating
Hx of mTBI
(Index Score Range)
(N = 17)
Average (90-109)
10
Below Average (80-89)
3
Weak (70-79)
1
Very Weak (<70)
3
Note. Hx = history; mTBI = mild traumatic brain injury.

18

No Hx of mTBI
(N = 16)
7
3
2
4

Research Question 2: TAWF-2, BT Performance Frequency of Incident
A one-way between subjects analysis of variance (ANOVA) was conducted to
compare raw scores on TAWF-2, BT in individuals with 0 mTBI, 1 mTBI, 2 mTBIs, and
3 or more mTBIs. There was no significant difference at the p<0.05 level for the four
groups [F(3, 29) = 0.434, p = 0.730]. These results suggest that the number of mTBI
experienced does not affect TAWF-2, BT performance. Specifically, these results suggest
that an increased number of mTBI may not affect word-finding ability in the postsubacute phase of mTBI.

19

CHAPTER V
DISCUSSION
Implications
The purpose of the present study was to determine if individuals with a history of
mTBI demonstrate reduced word-finding performance compared to individuals without a
history of mTBI. No significant difference was found between TAWF-2, BT raw scores
and Word Finding Index of participants with a history of mTBI and the control group.
This finding did not confirm the hypothesis that individuals with a history of mTBI
would perform worse than those without a history of mTBI, as previous research has
indicated that individuals with a history of mTBI demonstrate slower response times and
commit more errors compared to individuals without a history of mTBI when performing
word-finding tasks (Barrow et al., 2006; King et al., 2006; 2006; & Norman, Shah, &
Turkstra, 2019). This contrast may be explained by the fact that the subject pool in
previous studies included older adults, whereas the current study focused on young adults
for the purpose of attempting to eliminate the effects of aging on word-finding ability.
Additionally, mTBIs typically results in diffuse damage, which may explain the diverse
findings in previous research. Participants with a history of mTBI are a highly
20

heterogeneous group, and young adults may have experienced different patterns of
spontaneous recovery than older adults. Variability in outcomes is typically seen with a
small subject group as well.
King et al. (2006) and King et al. (2006) used the same mode of assessment in
their studies, which was the TAWF, an earlier publication of the TAWF-2, BT.
Participants with a history of mTBI demonstrated impaired word-finding ability in their
studies, but the time of testing post-injury ranged from the acute to subacute phase (i.e.,
4-37 days; 2-14 days). Participants in the current study were tested in the post-subacute
phase of injury, which ranged from 18 years to 10 months. This broad recovery window
used to indicate the post-subacute phase in the current study may have affected the
participants’ word-finding performance, perhaps improving word-finding performance as
additional time post-injury led to recovery of cognitive and linguistic skills.
The relationship between the reported number of mTBI and word-finding
performance was examined, hypothesizing that those with an increased number of mTBI
would perform worse on the TAWF-2, BT. No significant difference was found between
the TAWF-2, BT raw scores of those with 0 mTBI, 1 mTBI, 2 mTBIs, or 3 or more
mTBIs. This result is in line with what Stockbridge and Newman (2019) found in their
study when targeting cognitive and linguistic skills in isolation, as significant differences
were not observed between individuals with and without a history of mTBI when
performing a confrontation naming task. However, Stockbridge and Newman (2019)
additionally analyzed narrative writing tasks between individuals with and without a
history of mTBI and noted a significant increased use of GAP verbs among those with a
history of mTBI, which potentially signifies word-finding deficits. This finding contrasts
21

with those of the present study, though word-finding was targeted in isolation and not
through narrative writing. This might be due to the amount of brain involvement required
for narrative writing, which requires more engagement among areas of the brain than are
required for confrontation naming tasks. Confrontation naming tasks are more similar to
day to day word-finding challenges and do not require the same level of linguistic
complexity as written narratives, such as use of appropriate syntax.
It was of interest to examine the relationship between performance on the
TAWF-2, BT and the participants’ perceptions of the presence or absence of wordfinding issues in day to day life. Participants answered three yes/no questions related to
word-finding ability on the case history form prior to completing the TAWF-2, BT in
order to determine if their scores correlated with their perceived ability. If the participants
circled “yes” to all three questions, they were believed to perceive a word-finding deficit.
A review of the data that was gathered revealed that only 2 participants indicated on the
case history form that they had perceived the presence of word-finding issues in day to
day life, and both of these participants scored below the standard score of 85 on the
TAWF-2, BT. However, a total of thirteen participants scored below the standard score of
85 on the TAWF-2, BT; 6 from the mTBI group and 7 from the control group. This
suggests that individuals who believe they demonstrate word-finding issues in day to day
life may not exhibit word-finding issues on standardized assessments, and vice versa. In
addition, participants may not be good reporters of their deficits. Since the researchers
were unaware of the participants’ word-finding ability prior to their mTBIs, the
participants’ perceptions could not be confirmed. Word-finding deficits may impact
individuals differently due to how often this skill may be necessary for their occupations,
22

social activities, or education classes. Thus, some individuals may not perceive a
noticeable difference in their abilities after the injury.
Limitations
There are several limitations to the current study that should be considered when
interpreting the results. First, it is important to note that mTBI history data were selfreported by the subjects and were not verified with medical records. It was presumed that
the subjects provided the correct number of mTBIs sustained, however, there could have
been variation in the reported data, as some subjects may have interpreted the term
“concussion” differently since there was no formal definition or criteria given by the
researcher. Thus, participants who did not report ever experiencing a concussion could
have had one at one point in their life. In addition, those who claimed that their health
histories did not include learning disability, language impairment, or speech or language
therapy services (exclusion criteria utilized in the study) on the case history form could
have had such disorders and services, whether formally diagnosed or not. This study was
limited by its small sample size and was not representative of the culturally diverse
university population.
While limitations were present, the current study had several positive attributes as
well. First, the subject group consisted of young adults, which should have eliminated
any possible influence of the natural impact of aging on word-finding ability. An
additional strength is that all examiners were trained following the same procedures
regarding test administration, scoring, and fidelity check system. Examiners were blinded
to which group the participant belonged to when administering the word-finding
assessment. The primary co-investigator administered the TAWF-2, BT to a limited
23

number of participants and was blinded to which group the participant belonged to until
after the assessment was completed.
Future Directions
Future studies investigating the effects of mTBI on word-finding ability should
aim to overcome these limitations by including an increased number of participants.
Variability in time post-injury should be reduced by focusing on smaller recovery
windows to better understand how specific time periods post-injury affect cognitive and
linguistic performance. Participants should be presented with a clear definition of mTBI,
and medical verification should be sought in order to confirm the medically diagnosed
number of mTBIs experienced by each participant and date of injury. The case history
form should include more questions that ask whether the participant experienced a loss of
consciousness or was hospitalized due to the injury. Research should be conducted on
individuals’ perceptions of word-finding deficits in day to day life after experiencing
mTBI, perhaps by comparing scores from a standardized assessment to a quality of life
questionnaire to measure of self-awareness of word-finding problems or a Likert scale to
determine the severity of the possible deficit. Additional research is needed on other
severities of TBI (i.e., moderate, severe), as well as word-finding during more complex
linguistic tasks, such as discourse, which require integration of skills with word-finding.
Future studies should consider the possibility of other diagnoses that may impact wordfinding ability.
Conclusion
In summary, the present study explored the impact of mTBI on word-finding
ability. Results of the study suggest that young adults with a history of mTBI may not
24

experience word-finding difficulties in the post-subacute phase of mTBI, despite the
number of incidences of mTBI. Due to the cognitive and linguistic deficits that often
occur following mTBI, it was expected that individuals with a history of mTBI would
demonstrate impaired word-finding ability when compared to individuals without a
history of mTBI. Cognitive and linguistic functioning falls within the scope of practice of
speech-language pathologists. Continuous monitoring, frequent follow-ups, and
providing education to those who have experienced single or multiple incidences of
mTBI is important for the early identification and intervention of possible cognitive and
linguistic deficits due to the injury. Additional research is necessary to determine if
further assessment and treatment of word-finding deficits is necessary for this population.

25

REFERENCES
Adult Hearing Screening. (2020). American Speech-Language-Hearing Association.
Retrieved from
https://www.asha.org/PRPSpecificTopic.aspx?folderid=8589942721&section=Ke
y_Issues
Barrow, I. M., Hough, M., Rastatter, M. P., Walker, M., Holbert, D., & Rotondo, M. F.
(2006). The effects of mild traumatic brain injury on confrontation naming in
adults. Brain Injury, 20(8), 845–855. https://doi.org/10.1080/02699050600832445
Centers for Disease Control and Prevention. (1997). Sports-related recurrent brain
injuries. Morbidity and Mortality Weekly Report, 46(10), 224–227.
https://www.cdc.gov/mmwr/preview/mmwrhtml/00046702.htm
Centers for Disease Control and Prevention (2003). Report to Congress on mild
traumatic brain injury in the United States: Steps to prevent a serious public
health problem. National Center for Injury Prevention and Control. Atlanta, GA.
https://www.cdc.gov/traumaticbraininjury/outcomes.html
Centers for Disease Control and Prevention. (2015). Report to Congress on traumatic
brain injury in the United States: Epidemiology and rehabilitation. National
Center for Injury Prevention and Control; Division of Unintentional Injury
Prevention. Atlanta, GA.
https://www.cdc.gov/traumaticbraininjury/pdf/TBI_Report_to_Congress_Epi_and
_Rehab-a.pdf
Centers for Disease Control and Prevention. (2019, March 4). Traumatic brain injury and
concussion. https://www.cdc.gov/traumaticbraininjury/index.html
26

Covassin, T., Moran, R., & Wilhelm, K. (2013). Concussion symptoms and
neurocognitive performance of high school and college athletes who incur
multiple concussions. American Journal of Sports Medicine, 41(12), 2885–2889.
https://doi.org/10.1177/0363546513499230
Fratantoni, J. M., Delarosa, B. L., Didehbani, N., Hart, J., & Kraut, M. A. (2017).
Electrophysiological correlates of word retrieval in traumatic brain injury. Journal
of Neurotrauma, 34(5), 1017–1021. https://doi.org/10.1089/neu.2016.4651
Gaetz, M., Goodman, D., & Weinberg, H. (2000). Electrophysiological evidence for the
cumulative effects of concussion. Brain Injury, 14(12), 1077–1088.
doi:10.1080/02699050050203577
Ganti, L., Khalid, H., Patel, P. S., Daneshvar, Y., Bodhit, A. N., & Peters, K. R. (2014).
Who gets post-concussion syndrome? An emergency department-based
prospective analysis. International Journal of Emergency Medicine, 7(31).
https://doi.org/10.1186/s12245-014-0031-6
German, D. J. (1990). Test of Adolescent and Adult Word Finding. Austin, TX: Pro-Ed.
German, D. J. (1991). Test of Word Finding in Discourse. Austin, TX: Pro-Ed.
German, D. J. (2016). Test of Adolescent/Adult Word Finding (2nd ed.). Austin, TX:
Pro-Ed.
Guskiewicz, K. M., McCrea, M., Marshall, S.W., Cantu, R. C., Randolph, C., Barr, W.,
Onate, J. A., & Kelly, J. P. (2003). Cumulative effects associated with recurrent
concussion in collegiate football players: The NCAA Concussion Study. Journal
of the American Medical Association, 290(19), 2549-2555.
doi:10.1001/jama.290.19.2549
27

Institute of Medicine and National Research Council. (2014). Sports-related concussions
in youth: Improving the science, changing the culture. Washington, DC: The
National Academies Press. https://doi.org/10.17226/18377
King, K. A., Hough, M. S., Walker, M. M., Rastatter, M., & Holbert, D. (2006). Mild
traumatic brain injury: Effects on naming in word retrieval and discourse. Brain
Injury, 20(7), 725–732. https://doi.org/10.1080/02699050600743824
King, K. A., Hough, M. S., Vos, P., Walker, M. M., & Givens, G. (2006). Word retrieval
following mild TBI: Implications for categorical deficits. Aphasiology, 20(2-4),
233–245. doi:10.1080/02687030500473155
Mayer, A. R., Quinn, D. K., & Master, C. L. (2017). The spectrum of mild traumatic
brain injury: A review. Neurology, 89(6), 623–632.
https://doi.org/10.1212/WNL.0000000000004214
McInnes, K., Friesen, C. L., MacKenzie, D. E., Westwood, D. A., & Boe, S. G. (2017).
Mild traumatic brain injury (mTBI) and chronic cognitive impairment: A scoping
review. PLoS ONE, 12(4), 1–19.
https://doi-org.navigator-esu.passhe.edu/10.1371/journal.pone.0174847
McWilliams, J., & Schmitter-Edgecombe, M. (2008). Semantic memory organization
during the early stage of recovery from traumatic brain injury. Brain Injury,
22(3), 243–253. https://doi.org/10.1080/02699050801935252
Miotto, E.C., Cinalli, F.Z., Serrao, V.T., Benute, G.G., Lucia, M.C., & Scaff, M. (2010).
Cognitive deficits in patients with mild to moderate traumatic brain injury.
Arquivos de Neuro-Psiquiatria, 68(6), 862-868. https://dx.doi.org/10.1590/S0004282X2010000600006
28

Moser, R. S. & Schatz, P. (2002). Enduring effects of concussion in youth athletes.
Archives of Clinical Neuropsychology, 17(1), 91–100.
https://doi.org/10.1093/arclin/17.1.91
Norman, R. S., Shah, M. N., & Turkstra, L. S. (2019). Reaction time and cognitivelinguistic performance in adults with mild traumatic brain injury. Brain Injury,
33(9), 1173-1183. doi:10.1080/02699052.2019.1632487
Popescu, M., Hughes, J. D., Popescu, E., Mikola, J., Merrifield, W., DeGraba, M., Riedy,
G., & DeGraba, T. J. (2017). Activation of dominant hemisphere association
cortex during naming as a function of cognitive performance in mild traumatic
brain injury: Insights into mechanisms of lexical access. NeuroImage: Clinical,
15, 741-752. https://doi.org/10.1016/j.nicl.2017.06.029.
Randolph, C., Millis, S., Barr, W.B., McCrea, M., Guskiewicz, K.M., Hammeke, T.A.,
Kelly, J.P. (2009). Concussion Symptom Inventory: An empirically-derived scale
for monitoring resolution of symptoms following sports-related concussion.
Archives of Clinical Neuropsychology, 24(3), 219–229.
Slobounov, S., Slobounov, E., Sebastianelli, W., Cao, C., & Newell, K. (2007).
Differential rate of recovery in athletes after first and second concussion episodes.
Neurosurgery, 61(2), 338–44. doi:10.1227/01.NEU.0000280001.03578.FF
Stockbridge, M. D. & Newman, R. (2019). Enduring cognitive and linguistic deficits in
individuals with a history of concussion. American Journal of Speech-Language
Pathology, 28(4), 1554–1570. https://doi.org/10.1044/2019_AJSLP-18-0196
Walker, M. M., Rastatter, M., & Holbert, D. (2006). Mild traumatic brain injury: Effects

29

on naming in word retrieval and discourse. Brain Injury, 20(7), 725–732.
https://doi.org/10.1080/02699050600743824
Whiteneck, G., Mellick, D., Brooks, C., Harrison-Felix, C., Noble, K., & Sendroy Terrill,
M. (2001). Colorado traumatic brain injury and follow up system data book.
Englewood, CO: Craig Hospital.

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Appendix A: Institutional Review Board Approval

31

Appendix B: Consent Form
INFORMED CONSENT
For a Research Study entitled
“The Impact of mTBI on Word-Finding Ability in Young Adults”
You are invited to participate in a research study that will examine if there a significant
difference in language test scores between young college students with a history of concussion
compared to those without a history of concussion. The study is being conducted by Lori
DeFazio, B.S. under the direction of LuAnn Batson-Magnuson, Ph.D., CCC-SLP in the East
Stroudsburg University Department of Communication Sciences and Disorders. You were
selected as a possible participant because you are between the ages of 18 and 24 years old and
you may or may not have experienced one or more concussions.
What will be involved if you participate? If you decide to participate in this research study,
you will be asked to complete a survey regarding your personal history of concussion, receive
a hearing screening, and participate in a brief language test that will assess your word finding
ability. Your total time commitment will be approximately 45 minutes.
Are there any risks or discomforts? No risks or discomforts beyond what would be expected
in everyday clinical interactions would be expected. The standardized evaluation is a standard
component in a clinical setting. Evaluation protocol are standardized and those with evidencebase to support their use. Psychological distress may occur during testing due to feelings of
frustration or embarrassment with test items. Subjects may discontinue testing at any time.
Are there any benefits to yourself or others? If you participate in this study, the expected
benefit will be to increase knowledge within the field of communication sciences and
disorders.
Will you receive compensation for participating? You will receive no financial
compensation for participating in the study.
Are there any costs? If you decide to participate, there will be no cost. I have no financial
interest to disclose regarding this study.
If you change your mind about participating, you can withdraw at any time during the
study. Your participation is completely voluntary. If you choose to withdraw, your data can be
withdrawn as long as it is identifiable. Your decision about whether or not to participate or to
stop participating will not jeopardize your future relations with East Stroudsburg University
or the Department of Communication Sciences and Disorders.
Your privacy will be protected. Any information obtained in connection with this study
will remain confidential. Information obtained through your participation may be published
in a professional journal or presented at a professional meeting.
Participant’s Initials ________

Page 1 of 2
32

If you have questions about this study, please ask them now or contact Lori DeFazio by
phone at (570)-905-7617 or e-mail at ldefazio@live.esu.edu or LuAnn Batson-Magnuson at
batsonmagn@esu.edu. A copy of this document will be given to you to keep.
If you have questions about your rights as a research participant, you may contact the
East Stroudsburg University Institutional Review Board by phone (570)-422-3336 or e-mail at
sdavis@po-box.esu.edu.
HAVING READ THE INFORMATION PROVIDED, YOU MUST DECIDE
WHETHER OR NOT YOU WISH TO PARTICIPATE IN THIS RESARCH
STUDY. YOUR SIGNATURE INDICATES YOUR WILLINGNESS TO
PARTICIPATE.

___________________________
Participant Signature
Date

______________________________
Investigator obtaining consent Date

___________________________
Printed Name

______________________________
Printed Name

______________________________
Co-Investigator
Date

______________________________
Printed Name

Page 2 of 2

33

Appendix C: Case History Form
Case History Form
Have you ever suffered from a concussion or head injury?
If yes, how many?

YES

NO

_______

What was the cause of the concussion(s)?

________________________________________________________________________

________________________________________________________________________

Were you diagnosed with a concussion by a doctor?

When was your most recent concussion?

YES

NO

____________________________________

Are you currently experiencing any symptoms resulting from the head injury? YES NO
If yes, please describe:

________________________________________________________________________

________________________________________________________________________
Did you ever receive speech or language therapy?

YES

NO

Do you have a history of any learning disabilities?

YES

NO

Do you struggle to think of the names of people, places, or objects? YES

NO

In response to questions from other people? YES

NO

During conversations?

NO

34

YES

Appendix D: Concussion Symptom Inventory (CSI)
Concussion Symptom Inventory (CSI)

Date of Birth: ____________________

absent
0

Sex: ______________

mild
1
2

moderate
3
4

severe
5
6
Score

Headache
Nausea
Balance problems/Dizziness
Fatigue
Drowsiness
Feeling like “in a fog”
Difficulty concentrating
Difficulty remembering
Sensitivity to light
Sensitivity to noise
Blurred vision
Feeling slowed down
TOTAL:
Other symptoms evident since injury?

Randolph, Millis, Barr, McCrea, Guskiewicz, Hammeke, & Kelly (2008)

35

Appendix E: Fidelity Procedures
Following test administration:
1. Examiner 1 verified accuracy of administration (correct number of items
administered, complete test administered, etc.)
2. Examiner 1 scored test.
3. Examiner 2 reviewed test score sheets and administration procedures.
4. If there was disagreement, examiners met to resolve any discrepancies, referring
to testing manuals or the co-investigators as needed.
5. A designated data entry person rechecked all tests for accurate scoring and
entered data into the master project spreadsheet.
Note: Throughout the duration of the study, co-investigators and selected
assessors completed fidelity observations of assessors while tests were being
administered to ensure all language, prompting, and testing procedures were
accurate and effective across examiners. If examiners exhibited difficulty with
test administration or scoring errors, additional training was provided.

36