Download Six Approaches to Cognitive Rehabilitation

Six Approaches to
Cognitive Rehabilitation
I have no financial relationships to disclose
Don MacLennan, MA, CCC
Chief, Speech Pathology Section
Minneapolis VA Health Care System
Goals of Workshop
Skill Set for Working with Brain-Injured People Returning to School
1
Assistive Technology
for Cognition
4
1. Identify six approaches to cognitive rehabilitation
2. Understand coaching as a process for rehabilitation
2
Knowledge of best practice
in cognitive rehabilitation
5
3
Knowledge of best practice
in academic strategies
3. Illustrate the six approaches to cognitive rehabilitation
across common areas of cognitive-communication
treatment
4. Understand a process for assistive technology for
cognition (ATC)
Collaborative
self-coaching
model of therapy
5. Understand application of cognitive rehabilitation
in return to school
Session Objectives
Acknowledgments
Staff at VA Health Care System
1. Define EBP and Cognitive Rehabilitation
Physical Therapists
2. Identify six approaches to cognitive rehabilitation
3. Discuss a ‘mindfulness approach to workbooks
RN Case Managers
Vocational Rehabilitation Specialists
Psychiatrists
Recreational Therapists
Psychologists
4. Understand coaching as a process for rehabilitation
Occupational Therapists
Social Workers
Students
Clinical Fellows
Nurses
Physiatrists
Speech Pathologists
Blind Rehabilitation Specialists
Physical Therapists
Acknowledgments - ANCDS
Mark Ylvisaker
McKay Sohlberg
Mary Kennedy
Lyn Turkstra
Acknowledgments - mTBI Toolkit Group
Acknowledgments
Acknowledgments
John Byler:You Look Great - Coming Home With Mild TBI
Service Members
& Veterans
Content Emphasis
Cognitive Rehabilitation
Theory
X
Practice
Evidence-Based Practice
Definition of Evidence-Based Practice (Golper et al, 2001)
Evidence-based practice involves the integration of 3 factors
•Evidence-based practice guidelines are explicit
descriptions of how patients should be
evaluated and treated.
•The purpose of guidelines is to assure
the quality of care by reducing unacceptable
variation in practice.
(Cicerone, 2005)
• Knowledge of the research literature
• Clinical experience
• Values and beliefs of the clients we serve
Evidence-Based Practice: Caveats (Montgomery & Turkstra, 2003)
Evidence for Brain Injury
“Statistically significant” does not necessarily mean clinically
meaningful
Clinicians must always use judgment in translating use
of evidence to individuals
Randomized Controlled Trials (RCTs) may be impractical
and even inappropriate for answering some clinical questions
•
Academy of Neurologic Communication
Disorders & Sciences (ANCDS)
•
National Reviews for Acquired Brain
Injury (NRABI)
•
ASHA compendium of EBP guidelines &
systematic review
•
Cochrane Collaboration
•
•
Centre for Reviews & Dissemination
(CRD)
National Centre for Biotechnology
Information
•
OT Seeker
•
Evidence Updates (BMJ Group &
McMaster University)
•
Physiotherapy Evidence Database
PsycBITE
•
SpeechBITE
•
Definition of Cognitive Rehabilitation
Cognitive Rehabilitation:
Six Different Approaches
The application of techniques and procedures and the
implementation of supports to allow individuals with
cognitive impairment to function as safely, productively
and independently as possible (Mateer, 2005)
A two-way interactive process whereby people with
neurological impairments work with professional staff,
families, and community members to alleviate the impact of
cognitive deficits (MacLennan, 2009)
Six Different Approaches to Cognitive Rehabilitation
Four Clinical Practice Reminders
Sohlberg, 2013
Applied to all treatment sessions regardless of approach to tx
Sohlberg, 2013
No single ‘right’ intervention in cognitive rehabilitation
1. Establish therapeutic alliance and engagement in tx
• metaphor - presidential advisor (Ylvisaker & Feeney, 1998)
• motivational interviewing (Rollnick, Miller & Butler, 2008)
A variety of methods are available to treat attention, memory,
and executive functions
Selection of a specific approach may depend on a number
of factors
2. Therapy is systematic and leads to meaningful change
• Clear session plan supports overall goals
• Integrated with other therapies
• patient preferences
• specific needs of the patient
• timelines for treatment
• previous treatment
Strategy
Planning
Strategy
Planning
(Sohlberg & Turkstra, 2011)
(Sohlberg & Turkstra, 2011)
Four Clinical Practice Reminders
Sohlberg, 2013
Applied to all treatment sessions regardless of approach to tx
1. Establish therapeutic alliance and engagement in tx
• metaphor - presidential advisor (Ylvisaker & Feeney, 1998)
• motivational interviewing (Rollnick, Miller & Butler, 2008)
2. Therapy is systematic and leads to meaningful change
• Clear session plan supports overall goals
• Integrated with other therapies
3. Techniques should accommodate/improve processing deficits
• Clear, systematic instruction
• Ample opportunity for practice
TEACH-M
4. Conduct ongoing evaluation of intervention
• Measurement of performance should guide treatment
Strategy
Knowledge
(Sohlberg & Turkstra, 2011)
Strategy
Monitoring
Approach I:
Personalized Education
& Understanding
(Sohlberg & Turkstra, 2011)
Approach #1: Personalized Education & Understanding
Approach #1: Personalized Education & Understanding
Sohlberg, 2013
Understand why education approach is being used
• Increasing awareness to support a compensatory strategy
• Validating symptoms to decreases symptom magnification or anxiety
• Increasing understanding of a condition to provide support and
decrease the sense of isolation
• Providing education about specific symptoms that will be tied to
specific behaviors or therapy
Sohlberg, 2013
Types of education
• Verbal discussion
• Presentation of written or
visual materials
- YouTube
- Handouts
- Individual case studies and
testimonials in books
• Experiential - observing performance
under different conditions
Approach #1: Personalized Education & Understanding
Approach #1: Personalized Education & Understanding
Sohlberg, 2013
Personalize the information: (discussion, written/visual materials)
• Highlight information most relevant
to the patient’s experience
• Write the next paragraph or edit
the material based on the personal
experience
Sohlberg, 2013
Personalize the information: (experiential education)
• Keep a log of cognitive challenges, behaviors, or feelings that relate
to the educational goal
• Ask trusted people about their perceptions of the information
presented and compare that with patient’s perceptions
• Design an experiment comparing performance using a compensatory
• Complete ‘Agree and Disagree’
Assignments
strategy with typical performance
Approach #1: Personalized Education & Understanding
Sohlberg, 2013
Balance education of strengths and weaknesses
• Difficult for people to hear about limitations and challenges
Approach 2:
Training Cognitive
Strategies
• Every person comes to therapy with strengths
• It is important that the person generate these strengths and
weaknesses
• It is important to highlight achievements in therapy to provide
ongoing education regarding their own self-efficacy
Approach #2: Training Cognitive Strategies
Approach #2: Training Cognitive Strategies
Sohlberg, 2013
Sohlberg, 2013
General Strategies: implemented across tasks or situations
Specific Strategies: relevant to a specific task or situation
Internal Cueing Strategies:
• Developing adaptive patterns of thinking to improve function
Strategy selection & introduction should be thoughtful &
systematic
• Clinician should be aware of the range of strategy options
Haskins EC et al (2012). Cognitive Rehabilitation
Manual. Reston VA: ACRM Publishing
Sohlberg, MM & Turkstra LS (2011)
Optimizing Cognitive Rehabilitation.
New York: Guilford Press
- General: Self-Talk, Goal Management Training, Time Pressure Management
- Specific:Visualizing Target Information; Acronym Formation
External Cueing Strategies:
• Implementing specific actions that improve functional ability
- General: Taking a Break, Asking for Help, Relaxation Breathing
- Specific: Cornell Note Taking
Approach #2: Training Cognitive Strategies
• Therapy selection is collaborative based on the problem
and the preferences and experiences of the person
• Therapy should ensure that person knows how, when and why
to use a strategy
Approach #2: Training Cognitive Strategies
Sohlberg, 2013
Therapy should provide for PRACTICE using the strategy
• Once person shows clear knowledge of how, when, and
why to use the strategy - provide ample practice using
the strategy
• Different antecedents or triggers for when to use
the strategy should be identified and explicitly practiced
Sohlberg, 2013
Evaluation of strategy USE should determine the type and
amount of practice
• Take session data on
- knowledge of how, when, and where to use strategy
- ability to recall and implement strategy with decreasing
levels of cueing
• Collect real-life data on
• Therapy should plan for practice using the strategy in
real-life situations
- use of a strategy in context (self-report/other report)
- impact of strategy use on the target problem
Direct Instruction: TEACH-M
(Ehrlhardt et al, 2005)
Setting a Calendar Appointment
Task Analysis
TEACH-M
Find the correct date
Type the name of the appointment
Errorless Learning
4. Press “ABC”
5. Use keyboard to type appointment - press “OK”
Set the time of the appointment
Assess Performance
Cumulative Review
Know the Instructional Content
High Rates of Correct Practice
- Break the content down into
small steps
Metacognitive Strategy Training
- Chain the steps together
TEACH-M
1. Press the calendar hot button twice - you will be in
single day view
2. If the appointment is in the future, press “Go To” &
then select month & day of the appointment
3. If the appointment is for today, continue to next step
Task Analysis
Errorless Learning
Enter the calendar section
Bad Research Experiment #1
Errorless vs Errorful Learning
6. Press “New”
7. Press “Start Time”
8. Press hour and minutes when your appointment starts
9. “End Time” automatically sets to 1 hour after start time
If your end time is different, press hour & minutes when
appointment ends
Set a reminder alarm
10. Press “Details”
11. Touch box that says “Alarm”
12. Default is in “minutes” - if you want alarm to ring hours
or days before the appt press “minutes” or “hours” and
change it
13. The default value is “10”- if you want to change it place
the cursor to the right of the number
14. Press “123”
15. Backspace to erase “10”
16. Type in desired number
17. Press “OK”
Errorful Learning
Goal is to learn 2 names
Write down 3 guesses for first name
- Write down correct name when presented
Write down 3 guesses for last name
- Write down correct name when presented
Errorful Learning
Errorful Learning
First name begins with T
Last name begins with R
First name begins with D
Last name begins with H
Errorful Learning
Errorless Learning
Don’t Guess!
First name is
Write down the name as it is presented
Last name is
Errorless Learning
Recall
Long-term vs short-term memory
• Short-term memory is in the moment
First name is
• Recall - presumes information is in long-term
Last name is
• When can we say information is in long-term
memory
memory?
about 20 seconds
ERRORLESS LEARNING
TEACH-M
• Keep errors to a minimum as the skill is being learned
ERRORLESS LEARNING
Bad Research Experiment #2
TEACH-M
Massed Practice: all rehearsal in at one time
Spaced Retrieval
Cramming
Distributed Practice: spread rehearsal & retrieval of information
• Model target step(s) before the patient attempts
each step
• Carefully fade supports and prompts
• If an error occurs, immediately demonstrate the correct
step and ask the patient to do it again
over time
Spaced Retrieval:
a form of distributed practice in which retrieval
occurs at progressively longer intervals
Massed Practice
Massed Practice
Guinea: National Motto
Guinea: National Motto
Work
Work
Justice
Justice
Solidarity
Solidarity
Massed Practice
Massed Practice
Guinea: National Motto
Guinea: National Motto
Work
Work
Justice
Justice
Solidarity
Solidarity
Spaced Retrieval Procedure
Canada: National Motto
TEACH-M
Present information and demonstrate comprehension
e.g. the first three steps for the iTouch App “Awesome Note” are:
1) Touch the app icon, 2) select a folder, 3) touch the “+” symbol
Peace
Order
Good Government
•
First retrieval at 1 minute
correct response
•
Second retrieval at 2 minutes
correct response
•
Third retrieval at 4 minutes
•
Fourth retrieval at 2 minutes
correct response
•
Fifth retrieval at 4 minutes
correct response
incorrect response
Canada: National Motto
Assess Performance
TEACH-M
TEACH-M
Single Entry Items
Peace
Order
Good Government
•
Initial Assessment
•
Probe Assessment
•
Final Assessment
TEACH-M
Initial Assessment
•
Probe Assessment
•
Final Assessment
Multiple Entry Items
•
You need to go to a medical appt
this Friday from 1000 to 1030. The
appointment is not at your usual
clinic. Instead, it is at the Nicollet
Clinic & you need to find someone
to drive you there. You need to
bring your insurance card & a
current list of medications. You also
have two questions to ask the Dr.:
1) do I need to have a sleep study?
& 2) what is my cholesterol level?
•
Initial Assessment
•
Probe Assessment
•
Probe Assessment
Final Assessment
•
How can be sure you will
remember these appointments
on time?
•
Final Assessment
Show me how to enter a to do
checklist in the Awesome Note app
Cumulative Review
TEACH-M
Final Assessment
•
Your speech therapy appts
will be daily Monday-Friday
Probe Assessment
TEACH-M
Initial Assessment
•
TEACH-M
Assess Performance
•
You have a speech therapy
appt this Weds 10-1100
Assess Performance
Assess Performance
•
•
•
Repeating the initial assessment
to demonstrate mastery
•
Regularly review previously learned skills
•
Shorter, more frequent sessions may be more
effective than fewer but longer sessions
High Rates of Correct Practice Trials
TEACH-M
Canada: National Motto
TEACH-M
Practice the skill
multiple times
per session
Peace
Lemoncello & Sohlberg, 2005
Distribute practice
over time
Order
Tasks like Group Prospective Memory Challenge
can help consolidate & retain information
Metacognitive
Strategy Training
TEACH-M
Prediction technique
encourages active
processing of material
Good Government
Canada: National Motto
TEACH-M
Peace
Within Session: patient is asked to identify which aspects of a
task will be easy and which will be difficult
Order
Outcomes Prediction:
• client asked to predict how long an assignment will take
•how many items will be completed on group prospective
memory task
Approach 3:
Training Assistive
Technology for Cognition
Good Government
Approach #3: Training Assistive Technology for Cognition
Sohlberg, 2013
Selection & introduction should be thoughtful & systematic
Therapy should provide for PRACTICE using the strategy
Evaluation of strategy USE should determine the type and
amount of practice
Approach #4: Direct Training of Cognitive Processes
Approach 4:
Direct Training of
Cognitive Processes
Sohlberg, 2013
Trains specific cognitive processes with a goal of improving
the underlying cognitive impairment
Drills focus on a specific cognitive processes
Drills are repeated over time & level of difficulty is increased
with progress
Tasks are not functional but are intended to target processing
of specific cognitive networks
Weak evidence for this approach
Attention
Approach #4: Direct Training of Cognitive Processes
Approach #4: Direct Training of Cognitive Processes
Sohlberg, 2013
Sohlberg, 2013
Therapy tasks should be organized according to a
theoretical model
• Example: - a theoretical model that is supported in the literature
for attention includes: sustained attention, selective attention,
alternating attention, working memory, suppression of responses
Provide sufficient repetition
• Sufficient intensity of training is critical for facilitating
reorganization of brain networks and/or establishing a cognitive
skill so that it becomes automatic
• Working from a model ensures a scientific basis for treatment
• The person will need to practice
hierarchies
drills outside the clinic
• Working from a model supports systematic implementation of
therapy as it informs assessment and treatment tasks
Approach #4: Direct Training of Cognitive Processes
Approach #4: Direct Training of Cognitive Processes
Sohlberg, 2013
Sohlberg, 2013
Use performance data to direct therapy
• Use data to inform decisions on
when to start, stop, or modify a
therapy task or program
• Different measures of performance may
be relevant to the target goal: e.g. accuracy,
latency of response, time to completion
• Exercises may improve due to practice effects
- must evaluate generalization of training to
functional goals
Combine drills with strategy training & functional tasks
• Integrate cognitive exercises with strategies that facilitate
functional activity related to the target goal
• Never put someone in front of a computer to simply complete
computer drills
- Can combine drills with use of strategies such as self-talk,
relaxation breathing
- Can combine drills with functional tasks - e.g. ambulation
Approach #5: Specific Skills Training
Sohlberg, 2013
Approach 5:
Specific Skills Training
Used when cognitive rehabilitation may be most
effective when directed at training on a specific life skill
• Skills can be related to
- specific vocational tasks
- household tasks
- leisure activities
• This approach may be part of teaching an everyday
routine
Approach #5: Specific Skills Training
Approach #5: Specific Skills Training
Sohlberg, 2013
Sohlberg, 2013
Define the task, steps and context
• Break the skill or task into steps
• Identify contexts where skill
will be used
• Identify supports that may be
needed to implement the skill
• Provide sufficient practice with
the skill in the context it will
be used
• Train until skill becomes automatic (train to mastery)
Approach 6:
Environmental
Modification
Therapy should provide appropriate practice with the
skill in natural contexts
• example:
use: WalkAid 3x day in the home, with min caregiver cueing
Define criteria for skill mastery and develop methods
to measure progress
• examples:
use: % correct donning/doffing per week
impact - gait: no abnormal trunk movement while walking
impact - caregiver burden: 1=stay home supervise
5=leave home with confidence
Approach #6: Environmental Management
Sohlberg, 2013
Modifying the environment to support an individual’s
cognitive skills in everyday activities
May be used as an adjunct to other cognitive strategie
for people with milder cognitive challenges
• Reducing turning off phone, TV, music while studying
May also be used when internal strategies are likely to
be effective
• Labeling cupboards to find personal belongings
Approach #6: Environmental Management
Approach #6: Environmental Management
Sohlberg, 2013
Sohlberg, 2013
Identification of the environmental system or modification
should be collaborative
Significant others should be involved in designing and
implementing the system
Cognitive Rehabilitation:
A Coaching Approach
ASHA SIG 2 Discussion:
Therapy Materials for Patients with ‘Higher-Level TBI’
McKay Sohlberg
“While it is good news that there are increasing amounts
of materials and programs available that have the
potential to be useful to people with high-level cognitive
impairments we must be careful not to revert to the old
days of ‘general stimulation.’”
“…there is no support in the literature for the idea that
having people with acquired cognitive impairments
engage in repetitive thinking exercise via computer
games or puzzles has any effect on speed of
processing or attention.”
Therapy should provide practice using or attending to the
system and generalized practice in the natural
environment facilitated by natural supports
Evaluate the person’s use or attention to the system
as well as the impact on the target goal
Expert
Opinion
ASHA SIG 2 Discussion:
Therapy Materials for Patients with ‘Higher-Level TBI’
Mary Kennedy
“While working on decontextualized activities…may
be easy and ‘practical’, there is little evidence that
our clients benefit in any functional or
practical ways.”
Several systematic reviews of the cognitive rehabilitation
literature conclude that, if functional goals are to be
achieved, then the therapy needs to be functional
and practical as well.
Evolution of Cognitive Rehabilitation
Wilson & Gracey, 2009
“We no longer find it acceptable to sit people in
front of a computer or workbook in the belief that
such exercises will result in improved cognitive
and, more importantly, social functioning.”
Evidence-Based Practice - ACRM
Executive Functions
•
•
•
•
•
•
Self-Awareness Training
Time Pressure Management
Self-Talk
Social Problem-Solving
Goal Management Training
ICRP Activity Analysis
Attention
•
•
•
•
•
•
Attention Process Training
APT Generalizing Activities
Time Pressure Management
Self-Talk
N-back
Hemi-Spatial Neglect
Haskins et al, 2013
Memory
External Compensation
• Orientation Notebook
• Memory Notebook
• Electronic Device
Memory Strategy Techniques
• Visual-Verbal Associations
• Visual-Verbal Schematics
• Visual-Peg Method
• Method of Loci
Organizational & Elaboration
Techniques
• 1st letter mnemonics
• Semantic Clustering
• PQRST
Evidence-Based
Practice
Workbooks & Computer Drills: Evidence?
No direct evidence - indirect evidence that it does not work
• Cicerone et al (2011)
Computer-based interventions may be considered as an adjunct to
clinician-guided treatment for the remediation of attention
- Sole reliance on repeated exposure and practice on computerbased tasks without some involvement and intervention by a
therapist is not recommended
Social Communication
•
Social Communication Groups
Workbooks & Computer Drills: Evidence?
Lyn Turkstra
SIG 2 Discussion
RE: starting intensive speech therapy in the
acute phase of neuro injury
“Interesting you mention attention training…as this
is one area where there have been a couple of studies
showing no benefit to early training.”
Novack et al, 1996
Structured Training
• Attention treatment “conceptualized on the basis
of a hierarchy of attentional skills as described by
Sohlberg & Mateer, 1987
Unstructured Training - Workbooks
Ponsford JL & Kinsella G (1988). Evaluation of a remedial
programme for attentional deficits following closed-head
injury. J Clin Exp Neuropsychol, 10(6), 693-708.
Novack TA, Caldwell, SG, Duke LW, Bergquist TF & Gage RJ
(1996). Focused versus unstructured intervention for Attention
Deficits after Traumatic Brain Injury. Journal of Head Trauma
Rehabilitation, 11(3), 52-60.
• The Thinking Skills Workbook: A Cognitive Skills
Manual for Adults
• Basic Thinking Skills
• Therapy Guide for the Adult with Language and
Speech Disorders
• Computer games involving memory and/or reasoning
Logic to Systematic Progression of Difficulty
Axiom of Treatment: maintain optimum level of challenge
The Case Against
Workbooks
Vygotsky (1978):
Optimal improvement occurs when a person is
systematically pushed beyond, but not too far beyond,
a current skill level
Vygotsky was referring to the development of skilled
performances in children in a natural context
Weaknesses of Workbooks
Factor Analysis & Tests
•
No support in Evidence-Based Practice
•
The example of factor analysis in tests
• i.e. tests may not test what they say they test
• and by extension, workbooks may not treat what
they say they treat
•
Tests claim to measure a variety of aspects of cognition
Factor analysis of a test provides a statistical
measurement of the number of different variables
actually measured by the test
Workbook tasks are decontextualized
If a test measures truly different aspects of cognition,
then they will correspond to different factors on
factor analysis
Ross Test of Information Processing - RIPA 2
•
•
•
•
•
•
•
•
•
•
Immediate Memory
Recent Memory
Temporal Orientation (recent memory)
Temporal Orientation (remote memory)
Spatial Orientation
Orientation to the Environment
Recall of General Information
Problem Solving and Abstract Reasoning
Organization
Auditory Processing & Retention
This begs the question:
Just because a workbook says it treats
a cognitive process such as attention, memory,
sequencing, organization, or problem-solving
doesn’t mean that it actually does so
RIPA 2 - claims to measure 10 aspects of cognition:
Factor analysis indicates it measures one factor
Turkstra, 2015
There is no evidence that general stimulation using
decontextualized cognitive, drills or games produces
meaningful change in a person’s everyday activities.
Workbooks & Computer Drills: Decontextualized
Workbooks may mirror functional everyday situations...BUT
Executive Functions - Problem Solving
Cannot be treated out of context
Initiate
Strategy
• Workbook exercises are always decontextualized
• Odds are remote that any workbook problem will be relevant
to an individual at the time of treatment
Evaluate
Strategy
Goal
Strategy
• No evidence that workbook drill generalizes to functional skills
Problem-solving workbook exercises may offer practice setting
a goal (decontextualized) and develop a plan - but offers no
capacity for engaging that plan, self-monitoring performance,
and ultimately evaluating the effectiveness of that plan
If you want people to learn
something, teach it to them.
Don’t teach them something
else and expect them
to figure it out later.
A Mindfulness
Approach to
Workbooks
(Detterman 1993)
Workbooks & Computer Drills: A mindfulness approach
• Stimulation approaches may have some benefit for certain types
of disorders - e.g. aphasia, attention
• Workbooks may work well for people in post-traumatic amnesia
to promote focused attention - i.e. provide a relevant response to
a specific question or problem
• May foster awareness of challenges in specific areas
• Some workbooks are geared towards application of individualized
functional strategies and include attempts to generalize to home
environments
• Problem-solving exercises may be used to introduce
and practice use of structured problem-solving guides
Ecologically Oriented
Neurorehabilitation
of Memory
Anthony Stringer, PhD
WOPR
W - write it down
O - organize
P - visualize using
peg mnemonics
R - rehearse
Ecologically Oriented Neurorehabilitation of Memory
Appointments & Future Tasks
Write
Write the activity on a calendar or
list of chores
Organize
Put activités or chores in an efficient or
convenient order
Picture
Use peg words to create a picture that
connects appointments with the time of
day or chores with their place
Rehearse
Practice recalling the appointments or
chores from your mental pictures
Using Workbooks
to Introduce
Cognitive Strategies
Goal
Problem Solving
Guide
Plan
Doing Therapy
Without
Workbooks
Do
Goal Management Training
Worksheet Adaptation
Review
(Miotto et al, 2009)
Workbook Task: Scheduling
Making Workbook Tasks Personally Relevant
Scheduling task their own therapy:
Scheduling task
Workbook Task: Sequencing
Sequencing Task
Workbook Tasks: Relevance
Relevant vs Irrelevant
Information Task
Functional Task: Building a Resume
Functional Task: Memory
Relevant information to include in a resume
•
Make a list of jobs
Dates of employment
Addresses
Name of Supervisor
•
Sequence the jobs
•
•
•
•
List of job duties
• organize duties
• sequence duties
• separate relevant from
irrelevant information
Remembering Medical Information
How many times have you known a veteran to
attend a medical appointment and not be able
to recall what the physician has said and recommended?
Attend medical appointment and facilitate strategy
smartpen
• voice memo app
• notes in journal app or notebook
•
Dynamic Coaching as a Treatment Approach
The Importance of Executive Functions
Dynamic Coaching
“For individuals with acquired brain injury, damage
to these [frontal] brain networks, and the associated
dysexecutive symptoms do more to determine
the extent of community integration than does
damage to any other cognitive symptom.”
(Sohlberg & Mateer, 2001)
70,000 thoughts a day
9,000 decisions a day
Executive Functions
Definition: integrative processes that determine goal-directed
and purposeful behavior in everyday life (Cicerone et al, 2000)
• Formulate goals
• Initiate behavior
• Anticipate consequences of actions
• Plan and organize behavior in logical sequences
Executive Functions (Dawson & Guare, 2012)
1. Response Inhibition
7. Organization
2. Working Memory
8. Time Management
3. Emotional Control
9. Goal-directed Persistence
4. Sustained Attention
10. Flexibility
5. Task Initiation
11. Metacognition
6. Planning/Prioritizing
Self-Regulation
A Model of
Self-Regulation
(Revised, Kennedy &
Coehlho, 2005)
Self-Regulation:
Self%Regula*on--
Allows individuals to manage cognitive skills, emotions and
behavior to direct their own actions & achieve goals
(revised,-Kennedy-and-Coelho,-2005)-
Goal-–-Self%monitor-
• Solve problems
• Adapt to change
• Be organized
• Engage in family/home, work school
Strategy-decision–-Self%control-
Execute-strategy--
Allows us to monitor and adapt behavior
to fit a particular context
Metacognitive beliefs/Awareness
1-
Self-Coaching
• Dynamic, collaborative approach that models and
explicitly instructs self-regulation as a process (Ylvisaker & Feeney, 1998)
Dynamic Coaching vs. Traditional Therapy (Kennedy, 2013)
Dynamic Coaching
person with cognitive challenges and coach to solve real life
problems identified by the person
• Goal is for person with cognitive challenges to internalize
process of self-regulation and begin to self-coach
• The real work (i.e. strategy implementation) is done outside
clinic, then reviewed and adapted as needed within sessions
Traditional Therapy
• Educate
• Educate
• Rely heavily on interview data
• Rely on test scores & behavior
• Clinician asks questions, provides
• Clinician identifies, instructs on
• Clinician provides structure for self-
• Clinician provides structure & content
and behavior
• Based on reciprocal adjusting and problem solving between
1
solutions. May educate on specific
strategies
• Client provides goals & strategies.
Implements strategy in real life context
regulation process.
• Client provides content
• Goals are process based
• Occurs in context, in real real time
• Less intensive e.g. 1 x weekly
strategies and guides practice in
strategies within clinic
for treatment
• Goals are product-based
• Occurs in and out of context
• More intensive e.g. 2-3 x weekly
Self-Regulation for Complex Activities (Kennedy, 2013)
1. Identify potential goals
6. Initiate strategy steps
2. Select a doable goal
7. Check: strategy use
3. Identify potential strategies
or solutions
8. Check: track performance
4. Select optimal strategy;
have backup
5. Create steps & materials
Text
10. Adjust goal and / or
Adjust strategy
Date:
Response
Massed Practice
Guinea: National Motto
Review
What have you done since last meeting?
Where did you use strategies?
How did you remember to use
strategies?
Where did you not use strategies?
Under what circumstances did you forget
to use strategies?
(Revised, Kennedy & Coelho, 2005)
9. Compare to goal & review
Participant:
Process
A Model of
Self-Regulation
4 = participant supplies information
and makes decisions
3 = clinician provides education
participant makes decision
2 = mod prompting for decisions
1 = max prompting for decisions
Work
Evaluate
Did strategy prediction match outcome?
What worked well with strategy?
What didn’t work well with strategy?
What was the level of effort required?
What happened when strategy wasn’t
used?
4 = participant supplies information
and makes decisions
3 = clinician provides education
participant makes decision
2 = mod prompting for decisions
1 = max prompting for decisions
Justice
Next Steps
If strategy worked well, where else might
it be used?
If strategy was partially effective, how can
it be adapted?
If strategy was ineffective - new strategy?
New areas of difficulty, new goals?
Feedback:
4 = participant supplies information
and makes decisions
3 = clinician provides education
participant makes decision
2 = mod prompting for decisions
1 = max prompting for decisions
Solidarity
4 = participant supplies information
and makes decisions
3 = clinician provides education
participant makes decision
2 = mod prompting for decisions
1 = max prompting for decisions
Canada: National Motto
TEACH-M
Peace
Questions????
Order
[email protected]
Good Government
References
References
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cognitive rehabilitation: Updated review of the literature from 2003-2008. Archives of Physical Medicine
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Lemoncello, R, & M Sohlberg. Practicing What the Instructional Research Preaches: How do medical SLPs
rate? (Poster Presentation). American Speech-Language-Hearing Association Annual Convention. San
Diego, CA. November 2005.
Dawson, P & Guare R (2012). Coaching Students with Executive Skills Deficits. New York: Guilford.
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Community Living. Veteran’s Affairs Physical Medicine & Rehabilitation Grand Rounds Webinar
References
Sohlberg MM & Turkstra LS (2011). Optimizing Cognitive Rehabilitation: Effective instructional
methods. New York: Guilford.
Sohlberg MM (2013). MTBI Toolkit: Some Background. Presented at Association of VA SpeechLanguage Pathologists Conference, San Francisco, April 21.
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Harvard University Press.
Wilson BA & Gracey F (2009). Towards a comprehensive model of cognitive rehabilitation. In BA Wilson, F
Gracey, JJ Evans & A Bateman (eds.). Neuropsychological Rehabilitation: Theory, models, therapy and
outcome. New York: Cambridge.
Ponsford J, Kinsella G (1991) The use of a rating scale of attentional behavior. Neuropsychological
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Sohlberg MM & Mateer CA (2001). Cognitive Rehabilitation: An integrated neuropsychological approach.
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