Neuro DMS3 F

CCHMC Outpatient NeuroRehabilitation
Team (ONRT)
Cognitive Rehabilitation of Children
d Ad l t and Adolescents:
Practical Strategies for the Home,
C it d S h l E i t Community, and School Environments
Stephanie Volker MS CCC-SLP Stephanie Volker MS CCC SLP
Director of the CCHMC Outpatient
Neurorehabilitation Team (ONRT)
Stephanie.volker@chmcc.org
66
th
Annual OSLHA Convention
March 9, 2012
Cognitive Rehabilitation- What will we
cover today?
Presentation Overview
Basics about cognitive rehabilitation- efficacy,
what is it?, who does it?, who can benefit? what is it?, who does it?, who can benefit?
Developing a process for cognitive rehab
Components of a cognitive rehab approach Components of a cognitive rehab approach
Factors to consider in the pediatric population
My approach for developing strategies (1-10) My approach for developing strategies (1-10)
Case studies and practical strategies
Cognitive Rehabilitation- Does it work?
Efficacy of Cognitive Rehabilitation
There is substantial evidence to support interventions for
attention, memory, social communication skills, executive
function, and for comprehensive-holistic neuropsychologic
h bilit ti ft TBI (Ci 2011) rehabilitation after TBI (Ciccerone, 2011)
There is substantial evidence to support cognitive rehabilitation
for people with TBI, including strategy training for mild memory
i i t t t t i i f t t tt ti d fi it d impairment, strategy training for postacute attention deficits, and
interventions for functional communication deficits. (Ciccerone,
2005)
Th i L l 2 id th t b h i l d iti kill There is Level 2 evidence that behavioural and cognitive skills
post ABI can be improved by participating in neurorehabilitation
or neurobehavioural programs (Braunling-Mcmorrowet al.,
2010) 2010).
Cognitive Rehabilitation- Does it work?
Efficacy of Cognitive Rehabilitation
There is substantial evidence to support the use of direct
attention training and metacognitive training after TBI to promote
the development of self-directed strategies during postacute
h bilit ti d f t li ti t l ld t k rehabilitation and foster generalization to real-world tasks.
(Ciccerone 2011)
Self-directed strategy training is recommended for the
di ti f ild d fi it ft TBI (Ci 2011) remediation of mild memory deficits after TBI. (Ciccerone 2011)
For impairments of higher cognitive functioning after TBI,
interventions that promote self-monitoring and self-regulation for
d fi it i ti f ti i (i l di i i d lf deficits in executive functioning (including impaired self-
awareness) and social communication skills interventions for
interpersonal and pragmatic conversational problems are
recommended after TBI (Ciccerone 2011) recommended after TBI. (Ciccerone 2011)
Cognitive Rehabilitation- Who Does It?
A variety of professions including SLPs
ASHA h id d t i d ti d ASHA has provided extensive recommendations and resources
for SLPs who work with persons with cognitive-communication
deficits
SLP i tti h t t th ith iti d fi it t SLPs in any setting who treat those with cognitive deficits, not
just SLPs in medical settings
For kids and adolescents, the school IS an appropriate setting to
d iti h bilit ti d h l SLP h ld b d i it do cognitive rehabilitation and school SLPs should be doing it
Cognitive deficits have a significant impact on academic
success and the school setting is the optimal place to provide
iti h b cognitive rehab
School is their real world
Cognitive Rehabilitation- Who can benefit?
Anyone who has experienced a
change/reduction in their thinking/cognitive
skills following a neurological illness or injury
OR
Anyone who has deficits in their
thinking/cognitive skills
The 2
nd
description is broader and can include those
with learning disabilities or a degenerative disease with learning disabilities or a degenerative disease
process, in addition to those with an acquired brain
injury (thoughts??)
Children as young as ??? (thoughts)
Cognitive Rehabilitation- What is it?
In the literature, there are a variety of definitions
or descriptions:
Summary: Summary:
Targets improved measurable and satisfying
functional outcomes following neurological injury
Targets recovery of cognitive deficits- directly
retraining those cognitive processes that have been
impaired by injury based on the notion that damaged impaired by injury based on the notion that damaged
neural circuits can be retrained if they have been
partially or substantially spared after injury
Targets training in the use of compensatory
strategies to enhance performance on everyday
tasks tasks
Cognitive Rehabilitation- What is it?
In the literature, there are a variety of definitions
or descriptions:
Summary:
Involves metacognitive training
Consists of a variety of intervention strategies
and techniques (both group and individual)
Highly individualized (patients and families
are involved in setting goals and measuring
outcomes) outcomes)
Can be provided by a variety of professionals
Cognitive Rehabilitation-
How to Do It (My personal approach/philosophy)
My Background
6 years OP rehab with
adults in acute care, IP
Over time I developed a
process (for a long time,
rehab, and OP rehab
10 years OP rehab with
children adolescents &
I didnt even realize it
was a process)
Realized it when I children, adolescents &
young adults
So fortunate to have
Realized it when I
started to train
developmental
h i h
been able to specialize
in kids with ABI
therapists re: how to
apply rehab techs.,
specifically strategy p y gy
development
Developing My Process
I see clients with acute injuries, old injuries,
learning disabilities learning disabilities
Depending on the etiology of the deficit, the
clients background, the familys experience g , y p
with prior treatment.each client may need
only a part of the process
The trick is to figure out which part(s) of the
process they need a given time
Must Have Resource
Optimizing Cognitive Rehabilitation: Effective
Instructional Techniques
by McKay Moore Sohlberg and Lyn S. Turkstra (2011)
Instructional theory is critical to the delivery of effective y y
rehabilitation
Use a term called systematic instruction: persons with learning
challenges (like ABI) benefit most from structured training that g ( ) g
includes explicit models, errorless learning, strategies to
promote learner engagement, and carefully guided practice to
promote mastery, maintenance and generalization
Developed a training framework: PIE
Plan, Implement, Evaluate
**** Changing/shaping my approach and philosophy- we must Changing/shaping my approach and philosophy we must
continue to learn to become better at what we do.
Stay tuned..
Key Points to Keep in Mind
The goal of cognitive rehabilitation therapy is to help an
individual enhance his or her ability to move through daily life by
recovering skills or compensating for damaged cognitive
Goals must be
functional and SMART*
Family support and
involvement is crucial
functions.
functional and SMART*
Highly individualized
involvement is crucial
Client is the most
important member of
the team
S- specific, M- measureable, A- attainable, R- realistic/resourced, T- timely & time
bonded
Cognitive Rehabilitation Targets Improved
Functional Outcomes
Extensive patient/family education
Stimulation for recovery of underlying skills y y g
Development/training for compensatory strategies
Education Education
Stimulation Strategies
Cognitive Rehabilitation- Malia and Brannagan
Cognitive Rehabilitation Therapy (CRT)
Process
Training Training
Strategy
T i i
Ed ti
Training
Functional
A ti iti Education Activities
Training
Malia, Brannagan Volker
Process
Training
Education
Training
Strategy
Training
Education
Training
Functional
Activities
T i i
Training
Cognitive Rehabilitation: Education
Malia and Brannagan
Education- Therapist is a Teacher
1
st
provide GENERAL education
the neuroanatomy of the
brain, physiology, mechanics
of injury to the brain
Emotional consequences of
an ABI
C i kill
1 provide GENERAL education
of injury to the brain
Role of insight into problems
and how insight is impacted
after an ABI
Coping skills
2
nd
Provide SPECIFIC
education after an ABI
Patterns of recovery from
ABI
Th d 4 t f
education
The clients deficits and
impact on his/her life
The process and 4 parts of
CRT
Cognitive functions and how
th i t d i ABI
impact on his/her life
they are impacted in ABI
Cognitive Rehabilitation: Process Training
Malia and Brannagan
Process Training
An analysis identifies With correct kind of An analysis identifies
the deficient underlying
key cognitive processes
With correct kind of
stimulation, new neurons
can create optimal neural
th d t l t
Training exercises are
designed to improve a
particular deficit
pathways and templates
Cells that fire together,
wire together particular deficit
Exercises usually
involved pen/paper,
di l
wire together
A direct retraining of
cognitive processes can
lt i i ti f remedial games,
computer tasks
result in reorganization of
higher level thought
processes p
Cognitive Rehabilitation: Process Training
Example
Attention Process Training by Sohlberg
and Mateer
The Attention Process Training Programs (APT) by Sohlberg and Mateer are
based on extensive research that is widely published in the cognitive
rehabilitation and the disability literature.
These therapeutic treatment programs are designed for adolescents, adults and p p g g ,
veterans with mild, moderate and severe traumatic brain injury (TBI), post
concussion syndrome and other neurological disorders.
The Pay Attention Program by Thomson and Kerns is based on the APT
programand has been modified for children ages 4-11 with traumatic brain program and has been modified for children ages 4 11 with traumatic brain
injury or ADHD
Based on premise that repeated taxing of the same neurological system
facilitates and guides the restoration of function
P ifi h i th ti t t l t titi i Process specific approach requires the patient to complete repetitive exercises
targeting attention with increasing demands so that continued stimulation and
activation of targeted cognitive processes can occur.
APT programs available at http://www.lapublishing.com/attention-process-
training-apt/
Cognitive Rehabilitation: Strategy Training
Malia and Brannagan
Strategy Training
Strategies are taught to
compensate for deficits
Complementary to the
This is not an easy
option, whole books
have been written about
Complementary to the
process training since if
a deficit does not
have been written about
this process
Ex. IP rehab give them
improve, strategy
training aims to teach
the person how to
a memory notebook
Takes a long time
Not everyone can
p
bypass the problem
The problem is still
th b t th f ti l
Not everyone can
benefit from, or use
strategies
there, but the functional
impact of it is minimized
Malia and Brannagan
Strategy Training
3 categories of strategies
Environmental Strategies (accommodations) g ( )
those which the individual does not have to take any responsibility
typically used with severely injured patients.
Altering the environment around the individual g
External Strategies (strategies)
The person relies on others, physical objects, or devices.
Ex. Computer, iPad, cell phone, lists, calendar, watches, alarms Ex. Computer, iPad, cell phone, lists, calendar, watches, alarms
Internal Strategies (strategies)
Person relies on him or herself
Cannot be physically touched, they are inside the persons head Cannot be physically touched, they are inside the persons head
Ex. visualization, association, mnemonics, retracing
Malia and Brannagan
Successful Strategy Training:
Insight and Practice
Good insight/awareness, is the key to successful use
of strategies
Insight and Practice
g
Building metacognition is a crucial step in therapy
If the client does not, or cannot, recognize the
problems due to an insight or awareness problem,
he/she will not see the need to use a strategy
Even with awareness and insight it takes a significant Even with awareness and insight, it takes a significant
amount of time and practice to make the use of a
strategy- routine or habitual
Strategy training must be done with the
client, family, friends, teachers, etc.
Cognitive Rehabilitation: Functional Activities
Training Malia and Brannagan
Functional Activities Training
Using functional activities to work on deficient cognitive
skills that have been identified by assessment
The functional task is used as a treatment medium
Any activity has the potential to be used to treat a
iti bl j t d d h th ti it i cognitive problem, just depends on how the activity is
structured, how the task is analyzed, the level of
difficulty that is chosen, the cues provided, and the
outcome measures used
OTs may be more adept at using this technique than
SLPs but they shouldnt be SLP s, but they shouldnt be
Malia, Brannagan Volker
Process
Training
Education
Training
Strategy
Training
Education
Training
Functional
Activities
T i i
Training
Cognitive Rehabilitation- Who can benefit?
Children and adolescents who have
sustained an acquired brain injury (ABI)
Traumatic brain injury
Hemorrhages (inter-
Metabolic
encephalopathy
cerebral, intra-cranial,
subarachnoid) due to
aneurysm or AVM
Brain tumor resection
Abscess or sinusitis
Seizure disorder
CVA (stroke)
Infection: meningitis,
encephalitis cerebritis
Seizure disorder
Seizure focus resection
Hemispherectomy for
encephalitis, cerebritis
Anoxia/hypoxia
Toxic encephalopathy
p y
control of seizures
Progressive neurological
diseases
(drug overdose)
diseases
Application to the Pediatric Population
Factors which impact recovery in pediatric
brain injury j y
Predicting recovery and long-term outcome following
a brain injury is a complicated process, dependent on
a number of factors, including:
Length of time elapsed since injury (have a better idea after
one year what the outcome will be) y )
Premorbid language/cognitive abilities
Family support
Neurological damage sustained Neurological damage sustained
The age of the child at time of injury: Damage to a still
developing brain
Ch i t ti d bilit t Change in symptoms over time and ability to
compensate
Neurological factors
Severity: The more severe the damage to the brain as Severity: The more severe the damage to the brain as
measured by longer coma or post-traumatic amnesia, the more
problems in cognitive and behavioral functioning are likely to
appear later on.
Location: Children with more damage to frontal brain regions
may experience changes in personality and behavior, yet
maintain relatively intact the cognitive functions mediated by the
posterior regions Similarly children with more damage to white posterior regions. Similarly, children with more damage to white
matter may have more problems in information processing
speed, complex attention and organization despite having
normal language skills, academic skills and/or IQ.
Type: Whether the injury caused diffuse or focal damage.
Children with diffuse damage may be more severely
compromised.
Age of child at time of injury
O f h i i h i One of the most common misconceptions that exists
is that an ABI sustained earlier in life leads to a more
favorable outcome compared to an injury sustained p j y
later in life
The conventional thinking regarding TBI in young
people was that the childs brain was incredibly people was that the childs brain was incredibly
resilient to trauma because it was much more
plastic than the adult brain, i.e., that other parts of
the brain would take over for damaged parts
The earlier the better
Y b i h l f t Young brains heal faster
They can outgrow it
Damage to a still developing brain.
(Savage, 2009.)
The brains of children, adolescents and young adults are not
static, but rather develop in leaps and spurts throughout
childhood and well into the mid twenties of young adulthood childhood and well into the mid-twenties of young adulthood.
ABI can have a negative impact on continued brain maturation
and development in young people as they get older and grow
into their adult years into their adult years
Current neuroscience research has identified that children,
adolescents and young adults pass through five neuro-
developmental stages between birth and 21+years developmental stages between birth and 21+ years
Neuroscience research has further identified that different
regions of the brain (i.e., frontal-temporal region, temporal-
central region occipital parietal region) have different periods of central region, occipital-parietal region) have different periods of
developmental maturation.
Neurocognitive Stall
(Chapman, 2007)
Young people who have severe brain injuries may be at risk for
manifesting a neuro-cognitive stall during a second phase of
b i brain recovery
Neuro-cognitive stall as defined by Chapman (2007) is a halting
or slowing in later stages of cognition, social, and motor
d l t b d ft b i i j development beyond a year after brain injury
Despite sometimes remarkable recovery during the first year
after a TBI, young people appear to hit a wall or plateau and
t t l t d l t l il t not meet later developmental milestones
This neuro-cognitive stall may emerge despite the individual
seeming to have recovered cognitive abilities commensurate to
i j l l ones pre-injury level
Chapman, 2007
Slow Rate of Skill Development
Some injured children will develop
skills but at a slower rate than
normal with a decreased likelihood
of ever "catching up." g p
Shawna was a nine-year-old third
grader when she fell off a two-story
balcony and sustained a severe
TBI Her pre injury history was TBI. Her pre-injury history was
remarkable for being diagnosed with
an attention deficit disorder. With
treatment, she was able to maintain
average performance in school.
Followingher injury her medical Following her injury, her medical
and neurological status was normal,
but she had difficulty keeping pace
with her age-related peers in
reading, spelling and math
Growing Into Symptoms
Others show early medical and
neurological recovery and then
"grow into" their symptoms with
the passage of time the passage of time
Peter sustained a moderate TBI
in a motor vehicle/bicycle
accident as a seven-year-old
second grader. His pre-injury second grader. His pre injury
history was completely normal.
Once he returned to school, he
kept pace with his peers up until
the sixth grade, at which time
bl i i ti d problems in organization and
planning of schoolwork and
activities (executive functions)
became apparent.
The bar keeps getting raised.
As children and adolescents grow up with an ABI, the impact of
their deficits and their ability to compensate will change
A l b i d l th ld d th l As young peoples brains develop, the world around them also
becomes more complex and sophisticated. Learning in school
becomes more difficult, social and behavioral expectations
increase and the expectations of independence levels increase increase, and the expectations of independence levels increase
The impact of a neurocognitive stall, coupled with increasing
demands and challenges in the world around them, can lead to
a perception that these kids are getting worse a perception that these kids are getting worse .
They are not getting worse, but the functional impact of their
deficits can become more obvious and detrimental, i.e. they are
growing into their symptoms growing into their symptoms
Changes in Educational Demands
Holmes, 1987
GRADE 1 LEARNING TO LEARN & READ
GRADE 4 READING TO LEARN
MIDDLE
SCHOOL
LEARNING TO ORGANIZE
YOUR LEARNING
HIGH
SCHOOL
LEARNING TO LEARN, READ, &
ORGANIZE ON YOUR OWN
34
Changes in Educational Demands
1ST GRADE 7TH GRADE
Learning to learn
Learning to read
Regulating behavior
Attention, emotional and behavioral control
Structure and support
Lowcontent
Further increase in the quantity, depth, and
complexity of academic material
Further increase in the complexity of
psychosocial relationships including linguistic
and nonverbal demands
Decrease in contextual support from parents
d h
Low content
4TH GRADE
Increase in quantity, depth and complexity of
academic material
Decrease in contextual support
and teachers
Increased need for organization within the
learning experience
Need for more self-direction and self-initiation
Major developmental changes (physiological,
psychological, cognitive)
Change from "learning to read" to "reading to
learn"
Increased demand for organization and
processing of information for comprehension
New demands placed on existing cognitive
resources
y g g )
Increased peer demands
Increased demand for speed
HIGH SCHOOL
Further increases in quantity, depth and
Increased demand for speed
Increased demand for writing
Further increases in complexity of psychosocial
relationships
Continuing decrease in contextual support
Maximum demands on organization and speed
35
Context Content Interaction
N
Tcontext
A
M
O
U
N
A
content
1
st
4
th
7
th
9
th
GRADE
36
Bernstein & Waber, 1990
Optimal Context Content Interaction
for ABI Patients for ABI Patients
N
T
A
M
O
U
N
A
context
content
1
st
4
th
7
th
GRADE
9
th
context
Treatment for life .
Understanding ABI in this population as a developing Understanding ABI in this population as a developing
disability over time can help better manage this
disease-like process
A challenge for therapists is accurately predicting the
long term effects of ABI on young people so that
services and supports can be organized before services and supports can be organized before
deficits worsen and/or young people fail altogether
Clients needs may change with time due to the
changes in demands and the deficits they
demonstrate at any given time
Treatment for life .
Kids who have sustained an ABI and have a need Kids who have sustained an ABI and have a need
for cognitive rehabilitation may not fit the traditional
model of therapy services
In our program, we use a variety of models such as a
changing frequency, consultative, burst/intensive,
group and individual breaks fromtherapy and return group and individual, breaks from therapy and return
as needed for current challenges
I never really ever truly discharge anyone
The door is always open
Cognitive Rehabilitation- What do you treat?
Cognitive skills impacted by an ABI
O i i Orientation
Attention
Memory Memory
Problem Solving
Social Skills Social Skills
Reasoning
Executive Functions
Processing
Insight/Awareness
Cognitive Rehabilitation Targets Improved
Functional Outcomes
Extensive patient/family education
Stimulation for recovery of underlying skills y y g
Development/training for compensatory strategies
Education Education
Cognitive Rehabilitation- Strategy Development
Developing and Training in the Use of
Strategies and Accommodations g
Need to consider the
etiology of the deficit and
time since onset
HOW DO YOU KNOW
WHEN TO BEGIN??
time since onset
Potential for further skill
improvement
F ti l i t f th Functional impact of the
deficit (can you make an
impact right away with
strategies?) strategies?)
Motivation/comfort level of
patient/family
B t f i it Best of use visits
Process
Process for Developing Strategies for
Functional Independence Functional Independence
1. Determine a functional outcome goal g
2. Determine the deficits contributing to poor outcome
3. Educate patient/family re: deficit and goal
4. Probe patients insight/awareness of impact of deficit
and target this in therapy as needed (metacognition)
5 De elop a strateg /accommodation to achie e 5. Develop a strategy/accommodation to achieve
functional goal
Process
Functional Independence Functional Independence
6. Target the strategy in therapy to train the client in
use
7. Train the caregivers and support system
8 D l i f t t t h l li t 8. Develop reinforcement system to help generalize to
functional tasks
9 Target generalization of strategy to functional tasks 9. Target generalization of strategy to functional tasks
10.Once a strategy/step is mastered move on to the
next one
Process: Outcome Goal
Determine a Functional Outcome Goal
If the patient or family has many areas of need: choose
one that will be the LEAST challenging to target first for
fast success fast success
Examples:
Teacher would like child to complete in class work
i d d tl independently
Adolescent would like to be able to work the cash
register at fast food restaurant
Adolescent wants to be able to remember words and
motions to cheers
Parent wants child to be able to follow directions in the
home/school
Process
Functional Independence p
1. Determine a functional
outcome goal
2 Determine the deficits
6. Target the strategy in therapy
to train the client in use
7 Train the caregivers and
2. Determine the deficits
contributing to poor outcome
3. Educate patient/family re:
deficit and goal
7. Train the caregivers and
support system
8. Develop reinforcement system
to help generalize to functional
g
4. Probe patients
insight/awareness of impact
of deficit and target this in
th d d
tasks
9. Target generalization of
strategy to functional tasks
therapy as needed
(metacognition)
5. Develop a
strategy/accommodationto
10. Once a strategy/step is
mastered move on to the next
one
strategy/accommodation to
achieve functional goal
Cognitive Rehabilitation- Strategy Development:
Determine Deficits
Determine Which Deficits Contribute
You can do this by:
Reviewing assessment results (standardized
assessment)
Observe patient in functional tasks or ask them to
complete specific tasks designed to tease out p p g
deficits
May need patient/family to keep data
Ask specific questions designed to break down task Ask specific questions designed to break down task
into components and determine what the deficits
are (interview skills)
Determine Deficits
Sample Interview Questions: Attention
Do you ever feel as if you have
trouble paying
attention/concentrating?
D ti th t
Is he/she able to stay on task to
finish a job (dressing, HW, etc.)
How long can he/she stay on
t k? Do you notice that you are
easily distracted?
What types of things bother you
when you are doing HW?
H ll tt ti
task?
Are there differences in
attention depending on the time
of day, environment, mood?
Wh t d d t d i d How well can you pay attention
in class?
Do you feel as if you can pay
attention to more than one thing
at a time or is it all or nothing?
What do you need to do in order
to get his/her attention?
Can you talk to her while she is
doing something else?
Wh t t i k h t i d t
at a time or is it all or nothing ?
Do you lose your place if you
have to pay attention to
something else?
Howmuch work can you do
What tricks have you tried to
get his attention?
What are his big distractions?
How much cueing does he need
t ?
How much work can you do
before you lose focus?
to ______?
Determine Deficits
Example for Determining Deficits
Teacher would like child to complete in class
work independently.
Child cannot complete work independently
because.
did t tt d t th di ti d/ ld t did not attend to the directions and/or could not
process them
loses focus and attention and gets off task loses focus and attention and gets off task
(internal or external distractions?)
unable to remember all the steps
49
unable to problem solve through tasks
Determine Deficits
Example for Determining Deficits
Adolescent would like to be able to work the
cash register at her fast food job. She
cannot because.
she cant keep up with speed of
i f i b i id h h i information being said to her at the register
cant remember what it is she is supposed
t t h l th i t to get once she leaves the register
gets too distracted by noise that she is
unable to focus on the task
50
unable to focus on the task
Determine Deficits
Clinical Reasoning
We need to be detecti esand se the We need to be detectives and use the
combination of knowledge of neuroanatomy
and physiology past experience education of and physiology, past experience, education of
pt./family and good interview skills to gain
information from patient/caregiver, team p g
member report, observation in functional
activities, data collected from well-designed
t k t t l f i bl lit t d tasks to control for variables, literature and
best practices
CLINICAL REASONING IS CRUCIAL CLINICAL REASONING IS CRUCIAL
Determine Deficits
Clinical Reasoning
He cant follow directions
Attention: Did he pay attention? Will he maintain focus to
complete?
Processing: Was the information too much or too fast? Processing: Was the information too much or too fast?
Comprehension: Did he understand the vocab,
structure?
Encoding: Did he put the information into memory? (In
on ear and out the other)
Retention/Recall: Can he retain the information after a Retention/Recall: Can he retain the information after a
delay or in the midst of distractions?
Initiation: Will he initiate the task when needed?
Prospective Memory: Can he recall and initiate a task
at a specified time?
Process
outcome goal
deficit and goal
support system
g
4. Probe patients
th d d
tasks
therapy as needed
(metacognition)
5. Develop a
one
Education
Educate patient/family re: deficit and goal p y g
Once you have determined the skills which need to y
be targeted (for recovery or for development of
compensatory strategies) EDUCATION is involved in
every session every task every discussion every session, every task, every discussion
Education is the key to improving metacognitive
awareness and thereby developing and successfully y p g y
applying strategies
Education
Educate patient/family re: deficit and goal
Keys to successful education:
Knowing how much information to give
Taking into account the acceptance level and
emotional status of the patient/family
B f th b i f th ti t/f il Be aware of the buy in of the patient/family
What type of information to give, what method
Present at the correct rate and level (use analogies) Present at the correct rate and level (use analogies)
Use teaching moments
Active learning (patient writing) g (p g)
Ask what do you know? (attention ex.)
Education
Kinds of Attention
FOCUS
Able to pay attention
KEEPING FOCUS
Able to keep paying attention and
and concentrate
Able to keep paying attention and
focus as it takes to do the work
BLINDER FOCUS
Keep focus even when there
are distractions around. Put
on the blinders and block it
all out.
Education
Educate patient/family re: deficit and goal
If the patient/family is not ready to benefit from
education provided, you can:
Start to do activities to demonstrate deficits
Build trust and rapport with patient and family
Provide written materials for them to look over
outside of therapy
Proceed with other aspects of treatment,
move on and educate as you can
Process
outcome goal
deficit and goal
support system
g
4. Probe patients
th d d
tasks
therapy as needed
(metacognition)
5. Develop a
one
Metacognition
Determine Patients
Insight/Awareness and Target as Needed
Remember good
insight/awareness/metacognition is the key to insight/awareness/metacognition is the key to
successful strategy use
You may need to stay at this point for a while y y p
before moving on to developing strategies
There are different levels of
awareness/insight
How can you improve metacognition?
Metacognition
Probe Patients Insight/Awareness and
Target as Needed
Use pre-post self-assessments for tasks targeting
skill
Use self-evaluation forms and solicit feedback
from other sources
H ti t k j l Have patient keep a journal
Have others gently point out occurrences when
deficit impacts in real life p
Complete tasks in therapy and discuss patients
performance: then link to real world outcomes of
l l f f same level of performance
Metacognition
Improving Metacognitive Awareness with
Specific Tasks Specific Tasks
Client and therapist
i d d tl t
Client predicts how
well he/she will do
on the task
Client completes the
excercise
independently rate
how well he/she
thinks the client has
done on the task
discuss the
Education provided
as needed regarding
Therapist and client
discuss how the discuss the
similarities and
differences in the
ratings
as needed regarding
the skills which
were noted to be
deficient in the task
discuss how the
performance on the
task could be
improved
Metacognition
Improving Metacognition and Introducing
Strategies
Client predicts how
well he/she will do
on the task
exercise
independently rate
how well he/she
thinks the client has
done on the task
discuss the
similarities and
differences in the
ratings do e o t e tas at gs
Education provided
as needed regarding
th kill hi h
discuss how the
f th
develop specific
t t ( ) t
the skills which
were noted to be
deficient in the task
performance on the
task could be
improved
strategy(s) to
improve the
performance
task using new
strategies
Therapist can
provide cues as
needed to use the
strategies.
Client is improving
metacognitive
awareness and
training in use of
strategies
Metacognition
Can you improve metacognition in younger kids?
YES!! YES!!
Process (Using interrupting as an example)
1. Describe the deficit in language they understand (jump in,
d ) rudey)
2. Observe them and take a baseline of how often it occurred in a
task and provide them a visual representation (I use
il / d f ) smiley/sad faces)
3. Get them to accurately identify that deficit/behavior in others
(buzz game is fun!)
4. Once they can do that, establish a task and tell them you are
going to rate them and set a goal, i.e. was 10, now 8
5. Then see if they can self-rate and disinhibit that behavior
Metacognition
Case Study: Brandy
Brandy is a 16 year old girl who sustained a TBI in an MVA J uly Brandy is a 16 year old girl who sustained a TBI in an MVA J uly
2011.
Documented injuries include subcortical hemorrhagic contusions
of the parietal and frontal lobes of the parietal and frontal lobes
Spent 24 days in IP rehab, discharged and referred to OP rehab
at Cincinnati Children's Outpatient Neurorehabilitation Team
P i t TBI B d d ib d l t i f i dl Prior to TBI, Brandy described as popular, outgoing, friendly,
involved, somewhat scattered, but good student. Had IEP and
educational supports due to premorbid diagnosis of Wegener's
Granulomatosis and bronchiolitis obliterans which required Granulomatosis and bronchiolitis obliterans which required
frequent school absences
Brandy/family did not pursue OP therapy until November 2011
Metacognition
Case Study: Brandy
Initial evaluation: Brandy endorsed mild attention deficits but no Initial evaluation: Brandy endorsed mild attention deficits but no
impairments in memory, problem solving, processing, exec fx
Initial evaluation: Father endorsed mild attention and memory
deficits deficits
IE: mild decrease in AC, VE, RC, WE, moderate decrease in
attention, processing speed, memory, impulse control and a
reduced frustration tolerance reduced frustration tolerance
Initial sessions spent providing lots of education re: TBI,
expected deficits associated with her injuries, probing functional
impact of deficits with interviewquestions and activities impact of deficits with interview questions and activities
designed to demonstrate her deficits
She was accepting of the information, fun to work with, polite,
but no real buy into what I was selling but no real buy in to what I was selling
Case Study: Brandy
In 3
rd
session, got on board with the attention deficits after I
asked her to complete a simple worksheet and then brought in
different distractions (phone, talking, noise, laughing). Asked her
t t ll h ti h tt ti d d d i th t t k to tally how many times her attention wandered during that task
in 10 minutes- she stopped at 30
I also started to point out when she got the spacey look (her
d t ) h I t lki agreed upon term) when I was talking
We began to develop strategies for attention/focus and target
attention skills with APT II
She began to report functional gains by 5
th
session- more able
to block out noise in class, less bothered by distractions, more
aware of when she was and was not paying attention
Accomplished improved insight and metacognition for
strategy use
Metacognition
Case Study: Brandy
Next targeted improved insight to memory deficits
Even after she was buying the attention problems, she still did
not see her memory impairment (impact in school buffered by
her previous accommodations)
Started to play CD ROM games, Freddi Fish, to build insight to
memory deficits
Even though the games were somewhat juvenile, she had fun
with them and when she could not beat them, she began to
realize that it was due to memory impairment
At first I just observed, then began to point out memory
breakdown, then began to suggest strategies
She began to actively use strategies, improvement in game =
realization that they work
Generalization to functional activities is focus now
Goal- better memory for cheerleading
Metacognition
Insight Building with Rating Scale: Brandy
This questionnaire looks at some of the difficulties and changes that people
sometimes experience following a brain injury. Please read the following
statements and rate them on the two 5-point scales according to your
experience with Brandy Please be as accurate and honest as possible as this experience with Brandy. Please be as accurate and honest as possible, as this
information will be used by her therapist to determine progress and areas that
still need to be addressed in therapy. This is not intended to be a negative
tool, but rather one that points out Brandys progress, and areas that are still
seen as problems by others, of which she may be unaware. Brandy chose the p y , y y
people who will fill this out and she will also complete it about herself.
1. Brandy repeats herself in conversations.
Always Often Sometime Rarely Never
2. Brandy forgets details of conversations. 2. Brandy forgets details of conversations.
Always Often Sometime Rarely Never
3. Acts impulsively (without thinking ahead or thinking through something
fully)
Always Often Sometime Rarely Never Always Often Sometime Rarely Never
Metacognition
Insight Building with Rating Scale: Brandy
By the 10
th
session, Brandy agreed to fill out the rating scale and
provide it to friends and family
She endorsed functional impact of memory problems with
sometimesor oftenratings on 8/10 questions (family/friends sometimes or often ratings on 8/10 questions (family/friends
were commensurate)
She reported that her self-ratings changed significantly since
initiating therapy
She reported significant benefit from therapy as did 4/5 of friends
and family and all reported noticing functional improvement with
use of strategies
She was aware of her tendency to become irritated much more She was aware of her tendency to become irritated much more
easily and to act impulsively
She was not aware of her tendency to misunderstand
conversations and make mistakes when re-telling stories
Thi l d t d l t f t t i f i d h i This lead to development of strategies for improved comprehension
and retention of conversations
Process
outcome goal
deficit and goal
support system
g
4. Probe patients
th d d
tasks
therapy as needed
(metacognition)
5. Develop a
one
Develop a strategy/accommodation to
ALWAYS involve
the patient/ family in the patient/ family in
developing possible
strategies
Train parent/teacher Train the patient in
P id
Train parent/teacher
to use
a strategy
Train the patient in
using his/her own
strategy
Provide
an accommodation
Develop a strategy/accommodation to
achieve functional goal g
As a clinician, you should have a bag of
tricksto pull from tricks to pull from
Resources: books, continuing ed, how to
books, other populations (ADD, tourettes) , p p ( , )
Other patients, teachers, colleagues, parents
Have suggestions ready but be open to ideas Have suggestions ready but be open to ideas
from patients and caregivers
I have gotten great ideas from them! g g
K f l d l
Keys to successful strategy development
and use
The goal is to have the child/adolescent, with family
input, come up with the idea
To start, we create a chart describing the deficit, the
functional impact, the annoyance factor, possible
strategies strategies
Have them name the strategy to make it personal
Have them create a written or picture description of p p
the strategy
I have all of my kids keep a strategy notebook
hi h th k d k which they manage, make, and keep
Amy: Making sure I got it
Say What? Say What?
Ask others to
repeat
Put the Breaks
On!
information
Ask others to slow
down when they are
talking too fast talking too fast
Check It!
Re tell the Re-tell the
information
to verify I
got it
GET THE JOB DONE
What I am supposed
Start to work
to be doing?
Do I have everything I
Pay attention
No la la land
need?
Block out distractions
Dont talk about
things that pop in my
head
Keep going until its
done
76
JOB STOPPER: USESDISTRACTIONSTOSTOPYOUFROM
DOINGA JOB WELL ORFINISHINGA JOB HE TAKESAWAYYOUR DOINGA JOB WELL ORFINISHINGA JOB. HE TAKESAWAYYOUR
ATTENTION.
USE FOCUSMAN TOBLOCK THE JOB STOPPERSANDGET THE F MA H J PPR A G H
JOB DONE
VS VS
TOYS
TV
WHISKERS
PEOPLE
WHISKERS
ME M
Area of Challenge Possible Outcomes What I can do/Strategies
Allys Tools for Success
Math Dont understand what the teachers
talking about.
Wont be able to understand and then
catch up with the other students
I could ask my sister for help
I could ask my Dad for help
Ask the teacher for pointers before I
start to have problems
Writing Getting stuck
Difficulty getting the words on paper
Grammatical error
Awkward wording
Misspelling words
Use the How To Overcome Writers
Block paper
Hamburger Strategy
Somebody/someone check the paper for
me
Rereadingit or hearingit readaloud Rereading it or hearing it read aloud
Look it up in dictionary/thesaurus
Word Finding Not being able to come up with the
words that Im thinking in my brain
I feel stupid/
Mentioning that I struggle with word
finding out loud
Pause I feel stupid/
People find it difficult to talk to me
Pause
Rewording/using alternate words
Reading Comprehension Not understanding what Im reading
Have to read things sometimes two to
three times to understand it
Re-read material
Use Sparknotesto help
Outline
d l d Read aloud
Books on tape
BED TI ME ROUTI NE
1. GO POTTY
2 TAKE BATH 2. TAKE BATH
3. PUT ON PJS
4. BRUSH TEETH
5. BOOK TIME
6. PRAYERS/BED
Examples of Strategies and
Accommodations
Goal: Adolescent wants to work cash register at
her fast food job
Gi l b ll i Girl verbally repeats every item as customer
orders as she puts it into register, asks for repeat
as needed (Patient strategy)
Girl uses verbal rehearsal in order to remember
what to do once leaves register (i.e. get fries, 2
cokes, one frosty; get fries, 2 cokes, one frosty) , y; g , , y )
(Patient strategy)
Girl is able to work register only in low volume
times when only her register is open to decrease times when only her register is open to decrease
distractions (Accommodation)
Accommodations: Brandy
Attention strategies/accommodations
moved to front in all classes
asked friends not to talk with her in class
began to use Smart Pen- Live Scribe for note
t ki ( li ib ) taking (www.livescribe.com)
force field focus to block distractions
b k t f snap back to focus
honest with friends when she could not focus
on a conversation/story on a conversation/story
Accommodations: Brandy
Memory strategies/accommodations
Active Encoding purposefully put into memory
C ll h h i h (d d l i Cell phone home in each room (decreased losing
cell phone from 10x per day to 1x in a week, in only
one week)
repeat back to check accuracy of recall
honest with friends when she is full up
Self-rehearsal to hold information in memory for a Self-rehearsal to hold information in memory for a
short time
Videotaping cheer practice
Process
outcome goal
deficit and goal
support system
g
4. Probe patients
th d d
tasks
therapy as needed
(metacognition)
5. Develop a
one
Cognitive Rehabilitation- Strategy Training
Target the strategy in therapy to train the
client in use
This can take many, many hours of work
Goals are set which target the strategy use in Goals are set which target the strategy use in
increasingly complex tasks
Verbally describe
Demonstrate use
with minimal cues
Initiate use in
functional tasks Verbally describe
strategy
with minimal cues
in a structured
therapy task
functional tasks
with minimal
reminders
Learning Strategies
Therapist provides
ed cation re the St t D l d
Client completes a
education re: the
underlying skill
deficit
Strategy Developed
task which targets
use of the strategy
Use of strategy (s) is
targeted, measured,
Client gains practice
in use of strategy in
Increase difficulty of
tasks (structured to
and cued in
hierarchical fashion
in use of strategy in
tasks
tasks (structured to
functional)
Target the strategy in therapy to train the
client in use
This can be done with structured tasks or
functional activities functional activities
Whole books have been written about how to
train, what data to keep, when to move up , p, p
I like to introduce strategies in the context of
games or fun activities so the kids see benefit g
and get motivated
I like to use real life tasks such as school
and homework
Process
outcome goal
deficit and goal
support system
g
4. Probe patients
th d d
tasks
therapy as needed
(metacognition)
5. Develop a
one
Cognitive Rehabilitation- Training the
Support System
Train the caregivers and support system
The parent/caregiver(s) should already be familiar The parent/caregiver(s) should already be familiar
with the strategy since they helped develop it
Parent/caregiver should be observing (not g g (
necessarily in room) as the child/adolescent is trained
in use
They will need training in appropriate cues hierarchy They will need training in appropriate cues, hierarchy
of application (set goals)
Education for school personnel: background p g
information, description of deficits, examples of how
deficits could impact school, suggested strategies,
cues and plan if already developed cues and plan if already developed
Consistent use and cues is KEY!!!!!
Support System
Attention/Listening Strategies
Handout Provided to Parents/School
Alex has challenges in the following areas:
1. Attention (he cannot divide his attention so he
cannot process what is being said to him if he is
doing something else)
2. Speed of processing information/shifting attention p p g g
quickly (he cannot switch his focus off of playing
and then be ready to listen in the split second he
hears someone start to talk))
3. Encoding/Remembering information (he is not able
to remember information if he was not paying
attention in the first place) attention in the first place)
Support System
Handout Provided to Parents/School Handout Provided to Parents/School
However, we know that once you have his
attention, he IS able to listen, pay attention, attention, he IS able to listen, pay attention,
and remember information. The key is getting
his attention and making sure he is ready to
hear what is being said.
Our goal is for Alex to be able to listen to
instructions, pay attention and understand
them, remember them, and follow through
with them with them.
Support System
In therapy, we are using the following Step-By-Step
protocol to achieve this goal.
1 Use the commands EYES and HANDS to get his 1. Use the commands EYES and HANDS to get his
attention
He should turn his eyes to you and fold hands together
Keep repeating this and only this until you have his eyes Keep repeating this and only this until you have his eyes
on you and hands are folded
2. Once you have his attention, count to 5 (out loud or
to self) BEFORE talking to him ) g
This gives Alex the time he needs to transition his brain
to be ready to listen to what will be said to him.
It also gives him practice in holding attention and keeping
eyes on you eyes on you
Support System
3. Once he has eyes on you, hands folded, ready to listen, THEN
present the question or command. It is important that this be
presented in simple terms without too much information.
Good example: Alex what did you do in school today? Good example: Alex, what did you do in school today?
Too much information: Alex, did you have fun today at school? What did
you do? Did you play with water or did you have story time?
Good example: Alex, go get your shoes and bring them to me.
Too much information: Alex it is almost time to go so we need to have Too much information: Alex, it is almost time to go so we need to have
our shoes on or we wont be able to leave on time. Go get your shoes
right now so we wont be late.
4. Verify his comprehension/retention of what was said by having him
repeat it back to you.
Example: OK, what are you supposed to do?
Make sure he can tell you before you assume that he paid attention to
the information, encoded into his memory, or understood the question.
If he cannot repeat it back, present the information again. You may need
to repeat the EYES and HANDS command to regain his focus to repeat the EYES and HANDS command to regain his focus.
Support System
Education for school personnel: Example
J oshua is a 14 year old s/p meningitis who demonstrated mild- y p g
moderate deficits in processing speed, memory, and reading
comprehension.
These deficits greatly impacted him in the school environment and he
f l h l d b h i felt very overwhelmed by teachers expectations
His mother reported difficulty getting J oshua to communicate his
feelings to teachers and a feeling that the teachers just dont get it
So together we developeda rating scale which described his So, together, we developed a rating scale which described his
understanding/memory/grasp of material
We initially used this in therapy until I was sure that J oshuas ratings
were fairly accurate and he could demonstrate use in functional tasks were fairly accurate and he could demonstrate use in functional tasks
such as homework and reading assignments
The next step was transitioning use of this strategy to school. Initially a
letter was sent to his teachers and then a follow up phone call was
scheduled to discuss
The letter is as follows
Support System
The Understanding Scale
J oshua has demonstrated an improving awareness of his deficits,
and would likely benefit from use of a self-rating scale to increase
perception and awareness of his own perception and awareness of his own
comprehension/understanding of material he is taught. This can
also help his teachers monitor his understanding and learning of
material in light of all of his challenge areas Using this scale material in light of all of his challenge areas. Using this scale,
J oshua can report his perception of his own understanding of
material in order to provide feedback to his teachers and to
request help/clarification/further instruction when needed. An q p
example of this is provided as an attachment.
Support System
** This scale was developed by a therapist at CCHMC Outpatient
N h bilit ti T W thi i th d th ht it i ht b f l i Neurorehabilitation Team. We use this in therapy and thought it might be useful in
other settings as well.
**J oshua can use this scale to tell others how much he did or did not understand
information. It can be used for information he has read, something he was taught, or
something that was explained to him out loud. This scale can be used in several
different ways:
J oshua can do a self-rating to let others know how well he thinks he understood
information to help identify the need for re-teaching or further explanation. p y g p
J oshua can do a self-rating after hearing/reading/learning information once, then
complete questions or be quizzed, and then do a self-rating again to see if his
rating changed. This will help J oshua increase his own awareness of what he
does and does not understand well does and does not understand well.
Teachers/tutors/support personnel can use this rating to provide feedback to
J oshua about his understanding.
Cognitive Rehabilitation- Training
the Support System
1. J oshua feels as if he understood at least 90% of the information he has read/learned/heard. He
understood all or most of the ideas, main idea, and concepts. He has a good understanding and memory , , p g g y
of the information and could explain it back to someone else very easily. He could very easily do the work
without any examples to look off of.
2. J oshua feels as if understood most of the information he has read/learned/heard, about 75% of it. There
may have been a few ideas that did not make sense, but overall, he feels as if he understood the main
id d h h d d di d f h i f i d ld l i idea and concepts. he has a pretty good understanding and memory of the information and could explain
it back to someone else with a little help. he may have to use an example.
3. J oshua feels as if he understood about half of the information he has read/learned, around 50% of it.
There were ideas that he does not feel as if he understood the main idea and concepts. he does not have
a verygoodunderstandingandmemoryof the informationandneeds help to explainit back to someone a very good understanding and memory of the information and needs help to explain it back to someone
else. he would need to look off of examples to work the problem out on homework/tests.
4. J oshua feels as if she understood very little of the information he has read/learned, only about 25-35% of
it. There were a lot of ideas and concepts that did not make sense and he does not feel as if he
understood the main idea, but there were a few ideas and concepts that made sense. he does not have a
very good understanding and memory of the information and would only be able explain very little parts of
the information back to someone else. Even with examples he would probably need assistance on
working the problem out so that he puts the right information where it needs to be.
5. J oshua feels as if he did not understand the information he read/learned at all, less than 20% of it. he did
not feel as if she understoodthe main idea or anyconcepts he does not have an understandingor not feel as if she understood the main idea or any concepts. he does not have an understanding or
memory of the information and would not be able to explain the information back to someone else at all
because it does not make sense to him.
Process
outcome goal
deficit and goal
support system
g
4. Probe patients
th d d
tasks
therapy as needed
(metacognition)
5. Develop a
one
Cognitive Rehabilitation- Reinforcement to
Promote Use of Strategy to Functional Use
Develop reinforcement system to help
generalize to functional tasks
Some kids are not intrinsically motivated to
use strategies, even with good use strategies, even with good
insight/metacognition
In order for them to realize the benefits, and ,
for use of the strategy to become habitual, a
reinforcement system is VERY useful
Kids are used to them and if
caregiver/support team on board, it can work
t great
Decide on a Reinforcement
Strategy
Verbal, tangible, cumulative, immediate,
delayed
This can often be the most crucial point of
therapy
Often for a child/adolescent ho is sed to Often, for a child/adolescent who is used to
failure even when trying, he/she may not
see the point in using strategies
Reinforcement has to be positive
I like Chuck E. Cheese type
S t kl l f ll t d t Set weekly goals for use, collect data
Annes Weekly Goals
1 Checkmark indicating completed HW(1pt 1. Checkmark indicating completed HW (1pt
per day)
2. Accurate Bring Home list (1 pt per day) g ( p p y)
3. Have all items on Bring Home list in bag
by end of day study hall (1 pt)
4 Clean out folders and file papers 1x per 4. Clean out folders and file papers 1x per
week (5 points per week)
5. All assignments turned in for the week (10 g (
pts)
6. All papers in appropriate folders/files during
randomspot checks (3x: 10 points each) random spot checks (3x: 10 points each)
SPARKLE MY BOOKBAG
Briana
St ep 1: Al l f ol der s/paper s i n t he r i ght
pl ac e.. 1 pt
St ep 2: Penc i l s/suppl i es i n t he r i ght pl ac e 1 pt
St ep 3: Get Agenda si ghed / Agenda put
bac k i n t he cl i pped bag. 1 pt
St ep 4: Empt y Fun Fol der 1pt St ep 4: Empt y Fun Fol der 1pt
St ep 5: Al l Cl i ps, Hai r dos out of f r ont
zi pper /not messy!! 1pt zi pper /not messy!! 1pt
BONUSdoneallin1day 3pts
Process
outcome goal
deficit and goal
support system
g
4. Probe patients
th d d
tasks
therapy as needed
(metacognition)
5. Develop a
one
Cognitive Rehabilitation- Generalization of
Strategy Use in Functional Tasks
Generalization of strategy use in
functional tasks
Key points: with reinforcement, support, and cues as needed,
back away help gradually
You have to practice the strategyuse in the functional task or You have to practice the strategy use in the functional task or
one that mimics it
Break it up into small steps, give verbal and demonstration cues
P ti t ill d l t f l t f ti i i tti t k Patient will need lots of lots of practice in varying settings, task
difficulty levels, times of day, etc.
Gradually back off the help. Do not just quit help suddenly
Caregivers may need OK to pick out specific times to practice
Once a strategy/step is being used with
min/mod cues move on to another one min/mod cues, move on to another one
Cognitive Rehabilitation- Points to Keep in Mind
for Strategy Development/Training/Use
General Guidelines
about teaching/using new skills and
compensatory strategies compensatory strategies
Every person is different, every home/school is
different so taking a cookbookapproach to different so taking a cookbook approach to
strategies will not work. Strategies need to be
individualized, with input from the individual with
th bl i d t h h f the problems, in order to have any hope of
success.
General Guidelines
compensatory strategies
Establishing the success or failure of a particular
strategy takes a long time, you need to give things a
good shot before you abandon them as
f unsuccessful
It takes a long time to learn a strategy, there will
likely be a lot of slip-ups before they become routine likely be a lot of slip ups before they become routine
and they do need to become routine
If time management is an issue, pick out several
ti k t ti d h t times a week to practice and chart progress.
General Guidelines
Whatever the strategy, you should:
Provide lots of positive reinforcement Provide lots of positive reinforcement
Provide supportive, constructive feedback.
Sugar coating only makes the individual
perceive themselves as a lost cause perceive themselves as a lost cause
Pre-teach the skill/strategy. Dont assume
because you know what to do that the individual
d ( i l d) does (say it aloud)
Allow for lots and lots of practice, doing it
together many times. g y
General Guidelines
Whatever the strategy, you should:
Gradually withdrawsupport (skill emergence vs Gradually withdraw support (skill emergence vs.
skill mastery)
Not assume that because the individual can use
successfully in one setting, that they can in all
Step down expectations if the individual seems
frustrated then move back up frustrated, then move back up
General Guidelines
compensatory strategies
Get creative
Be CONSISTENT, CONSISTENT, CONSISTENT
Process
outcome goal
deficit and goal
support system
g
4. Probe patients
th d d
tasks
therapy as needed
(metacognition)
5. Develop a
one
Cognitive Rehabilitation- Treatment Tools
Computer Assisted Cognitive Rehab
Kids love computer games, already use them, Kids love computer games, already use them,
are motivated by them, rewarded by them, will
do them outside of therapy.
With kids/adolescents, computer games and
apps can be a goldmine for:
1. Underlying skill recovery
2. Building insight/metacognition
3. Developing strategies
4. Training/Practicing Strategies g g g
Comp ter games can be sed in s ch a
Computer Assisted Cognitive Rehab
Computer games can be used in such a
variety of ways, targeting different skills and
different phases of treatment (stim strats ) different phases of treatment (stim., strats.)
There is research going on to determine
efficacy (at least 2 at CCHMC) efficacy (at least 2 at CCHMC)
CD ROM games
Thinking Things Series, I SPY
Brain Spa Brainiversity Mind
Online games
Lumosity.com
H N
Brain Spa, Brainiversity, Mind
Quiz
Humongous Entertainment
games
HappyNeuron.com
regular kids websites
g
Humongous Entertainment Games: Freddi Fish
(also Putt Putt, Spy Fox, Pajama Sam)
A CD ROM game in which the user must help a central character solve a particular
mystery. Freddi Fish is leveled (1-5) with increasing difficulty and challenge to
certain skills. When playing the game, the following skills are stimulated/targeted:
Attention: the user must demonstrate focused attention to information
presented in the game in both an auditory and visual format, sustained attention
in order to play the game which can last up to 2 hours, selective attention by
blocking visual and auditory distractions in order to attend to pertinent g y p
information, and some aspects of divided attention by being able to attend to
both the visual and verbal aspects of the game and also to listen to characters
comments/directions while simultaneously processing visual information and
also engaging in active problem solving. g g g p g
Auditory Comprehension/Processing: user must process and comprehend
comments made by characters which provide instructions and clues. Comments
range from 1-3 sentences in length and can contain information which must be
inferred inferred.
(also Putt Putt, Spy Fox, Pajama Sam)
Memory: The user must demonstrate good visual recall in route finding and
spatial mapping in order to navigate through a labyrinth of destinations which
are interconnected. The user must also demonstrate ability to encode
information such as locations to visit or items to find during the game. This
information in turn must be retained over delayed time periods ranging from less
than one minute to up to 45 minutes, depending on the complexity level of the
game (1-5). The user then must retrieve the information at the appropriate time
to search for items or visits locations, and/or recognize items to retrieve when
encountering them. The amount of information which the user must encode,
hold in working memory, and utilize can range from 1 unit at a time to up to 35
units depending on the level of the game (1-5). Prospective memory is
challenged by the necessity of initiating actions at a any given time in the game.
Problem Solving/Logical Thinking: the user must recognize situational
problems and either recognize a solution which is shown on screen, or
determine a solution and then seek it out in the game. The user must also g
demonstrate the ability to recognize the format of the game and comprehend the
overall "goal" to solve the mystery.
(also Putt Putt, Spy Fox, Pajama Sam) ( , py , j )
Executive Function Skills: The user must demonstrate the ability to
initiate playing the game by clicking on appropriate items and
navigatingthrough the game independently. The user must initiate a navigating through the game independently. The user must initiate a
plan and carry it through while self-monitoring and adjusting plan based
on feedback
Insight Building/Metacognition: By playing the game, the user can begin
to realize breakdowns in each skill area with facilitation from therapist
as needed.
Strategy Use: Many different strategies for improved auditory
comprehension attention memory and problemsolving can be comprehension, attention, memory, and problem solving can be
taught/practiced when playing this game in a therapist directed format.
Ex: Brandy
Wrap-Up/Questions
Stephanie Volker MS CCC-SLP
Cincinnati Childrens Hospital Cincinnati Childrens Hospital
Director Outpatient Neurorehabilitation Team
513 636 3673 513-636-3673
Stephanie.volker@chmcc.org
Cognitive Rehabilitation- Case Studies and
Examples of Strategies
Case Study: Amber
Amber: a 20 year old female who was referred for treatment of persistent
cognitive deficits resulting from a subarachnoid hemorrhage secondary to
dissecting aneurysm of the left internal carotid artery 2 years ago. Amber had
recently returned to school as a college sophomore and student athlete, playing
basketball for her universitys Division 1 Top Ten nationally ranked team. She
was a previous A student, a lifelong high achiever, and was attempting a
double major in Education and Communication. Her daily schedule was
extremely busy and usually consisted of 2-5 hours of class time, 2-3 hours of
group practice, 1-2 hours of individual training, and then 1-4 hours of homework.
Upon initial evaluation Amber reported the following challenges: Upon initial evaluation, Amber reported the following challenges:
Persistent, and extreme mental and physical fatigue on a daily basis
Difficulty concentrating for long periods of time
Difficulty learning and remembering new information, including new plays for
basketball and notes for tests
Increased irritability and lowered frustration tolerance
Inability to pay attention to conversations with friends and a tendency to tune
people out and give up
Tendency to fall asleep when attempting to study
Case Study: Amber
Amber also reported:
She learned best on Sundays when she had been given a
chance to rest and was less stressed
She felt as if she was always a step behindwhen playing She felt as if she was always a step behind when playing
basketball
The assistant trainer for the universitys basketball team also
attended the evaluation and she reported: attended the evaluation and she reported:
Amber was often noticeably foggy and sluggish in practice
Amber required more 1:1 instruction and more hands on Amber required more 1:1 instruction and more hands on
practice to learn plays and information for basketball
Amber was reluctant to ask for breaks and often tried to hide
h f ti d tt ti / d fi it f h /t i her fatigue and attention/memory deficits from coaches/trainers
Case Study: Amber
Ambers Goal: To be able to concentrate and remember things
better for improved outcomes in school basketball and social better for improved outcomes in school, basketball, and social
settings (in that order)
1st Target: Cognitive Fatigue
Educated Amber and her trainer re: cognitive fatigue and the
impact that it had on Ambers daily functioning.
Developed several strategies to help Amber manage her Developed several strategies to help Amber manage her
cognitive fatigue
1. Modification of her daily schedule to allow rest
2. Self-rating scale to improve Ambers insight to her
cognitive fatigue (1-5 Likert scale)
3 M t f C iti F ti t l ith 3. Management of Cognitive Fatigue protocol with
guidelines and specific actions
Case Study: Amber
Cognitive Fatigue Rating Scale Amber Cognitive Fatigue Rating Scale- Amber
1. Totally zoned out/unable to focus/barely with it at all
2. Very poor attention, slow to react, not able to do task with best effort you.
3. Very tired, poor attention, can be focused briefly, memory poor. Noticeable to y p y y p
others who are looking for it, poor attention, decreased ability to learn, need
repetition of information more than normal, slow to get things
4. Starting to feel the effects of cognitive fatigue, energy waning, unable to fully
concentrate, decreased speed of thinking, sluggish. Even best effort on your concentrate, decreased speed of thinking, sluggish. Even best effort on your
part is still not enough to do well in task.
5. Able to focus with effort, a little bit in and out but can redirect self back when
needed. Energy pretty good, no one can notice impact of cognitive fatigue. Able
to learn/remember with effort to learn/remember with effort.
6. Good attention/focus, Really awake/lots of energy, no effects at all unless task is
super difficult, but able to do task with effort
7. Super focused, full of energy, able to learn and concentrate. Others do not
notice any problems in your learning.
Case Study: Amber
Managing My Cognitive Fatigue
Rules:
1-2 need sleep
3 stop working and longer break/rest
4 report how youre feeling, need a short break to stop the decline
5 OK to work, but start planning your break
6-7 okay to work
Schedule breaks
Make sure that you plan ahead and monitor your fatigue for activities
which require concentration/memory (studying, HW, practice)
Maximizing concentration
eliminate noises and distractions
work at a 5 or above
complete the most difficult work when you feel the freshest or most
alert (science first, etc.. dont save the hardest part for last)
Case Study: Amber
2
nd
Target: Attention
Ed t d A b t f tt ti d ibl t t i b Educated Amber re: types of attention and possible strategies, because
she was so high level, she did reading/research on her own
Amber participated in Attention/Process Training II with clinician
g idance to de elop better insight guidance to develop better insight
Amber and clinician developed personalized strategies to improve her
ability to manage attention
Began use of smart pen, Live Scribe Pulse, to assist with attention,
recall, and note taking in lectures
Began to open up to friends, family, teammates about her struggles and
asked that they respect her need for accommodations
Case Study: Amber
3
rd
Target: Memory g y
Educated Amber re: components of memory, the impact of
her attention and fatigue, and possible memory strategies
Amber chose & began use of several strategies for
studying including rewriting notes, daily review, schedule
review time just prior to test
New strategies for basketball: 1:1 with friend to physically
learn and practice new plays, video practice to watch to
learn better, audio recording of names of plays and
descriptions to music
Outcome: After 5 months in weekly treatment, Amber
was discharged after meeting her goal. was discharged after meeting her goal.
Memory Case Study: J ohn
J ohn is a 15 year old who was diagnosed with Complex 1
Mitochondrial Myopathy when in the second grade. Symptoms
which J ohn experiences as a result of his condition include
f ti ti i il th l l l i fatigue, tiring more easily than normal, leg muscle pain,
insomnia, myopia, and extraocular muscle fatigue.
He will enter his sophomore year of HS this fall and is serviced
with an IEP.
Provisions of his IEP include extended time to take tests, an
alternate environment to take tests, access to notes,
accommodations for physical needs, and individual meetings
with an intervention specialist 2x per week with an intervention specialist 2x per week.
J ohn is reportedly a good student, but has to work extremely
hard in order to do well in school. Both J ohn and his mother
report that memory and poor organization have always been
challenge areas for J ohn in regard to school challenge areas for J ohn in regard to school.
J ohn Evaluation
Review of neuropsychological results, patient interview, and
parent interview were utilized for evaluation purposes. Formal
standardized testing was not completed on this date since
lt f h l l ti il bl d results of neuropsychology evaluation were available and
current.
Both J ohn and his mother report that memory is a significant p y g
deterrent to J ohn's independence in functional tasks in the
home, community, and school environments. J ohn reported that
he feels as if his memory has gotten worse over the past year
and, as a result, his struggles with school and other tasks have , , gg
increased. Results of the neuropsychological evaluation
revealed a Wechsler Intelligence Scale for Children Full Scale
IQ of 93, but a very poor Working Memory Index of 65 (mean
100, +/- 15). , )
J ohn Evaluation cont
Reported functional outcomes of J ohn's memory impairment
include:
J ohn consistently misplaces items, such as his cell phone, and y p , p ,
is unable to recall where he put them.
J ohn reports that he has a very difficult time remembering
names or details about people he meets. He reports that this
has impacted himsocially because others interpret this as a lack has impacted him socially because others interpret this as a lack
of interest on his part.
J ohn demonstrates inability to recall details of conversations he
has had, which is frustrating for he, his family, and his friends.
J h h d t l diffi lt ti l i d i i J ohn had an extremely difficult time learning and memorizing
football plays last season.
J ohn takes a great deal longer to process and encode
information when studying and may need to learn information in y g y
a 1:1 environment or by himself when he is able to take extra
time to learn.
J ohn Evaluation cont
J ohn and his family have used various memory strategies with varying J ohn and his family have used various memory strategies with varying
success:
J ohn reports that when studying he will read over information
multiple times, use mnemonic devices such as acronyms or
t i d t ll li t sentence cues in order to recall lists.
J ohn often reviews information for tests just prior to taking a test.
J ohn inconsistently benefits from reminder cues re: the content of
conversations he has forgotten.
J ohn's mother reports that she has adjusted her style of
communicating information to J ohn. Namely, she limits the amount
of information she gives him at one time and will limit the details in
order to simplify the information so that he is able to recall it order to simplify the information so that he is able to recall it.
J ohn Evaluation Recommendations
Recommendations for Memory Strategies Recommendations for Memory Strategies
J ohn should trial keeping a small notebook with him at all times in
order to jot down information which he wants to remember. If
successful, this can later be used as groundwork for use of an
l t i t l id electronic external memory aid.
J ohn should initiate contact with his football coaches as soon as
possible in order to request copies of the plays which he will be possible in order to request copies of the plays which he will be
required to memorize this upcoming season. J ohn would greatly
benefit from a verbal discussion of the plays with a coach or another
player in order to try to encode the information in multiple modalities
(visually verbally) (visually, verbally).
J ohn can trial journaling at the end of the day in order to record
important events and details of conversations in order to increase
hi ll his recall.
J ohn Eval Recommendations
J ohn should initiate use of repetition strategy when meeting
someone new in order to try to encode and later recall that person's
name. For example, when meeting a new person, J ohn should state,
"It's nice to meet you J ane " He should also trial association as a Its nice to meet you J ane . He should also trial association as a
memory strategy, i.e. associating the name with something personal
or something which is already familiar to him. For example, he could
think to himself, "J ane is my neighbors name too". Use of either, or
both of these strategies can significantly increase the probability both, of these strategies can significantly increase the probability
that J ohn will be able later recall a name.
J ohn should practice the strategy of "Everything has a place and
everything in its place". For example, find a specific spot (both
t i d d t i ) i hi h h i t tl t hi ll h upstairs and downstairs) in which he consistently puts his cell phone
and be consistent in using this spot.
In order to remember to take something with him when he leaves
the house, he should put it in front of the door he will use to leave in p
order to remember to take it with him.
Case Study for Executive Dysfunction:
Anne Anne
Anne (age 10) had been seen for outpatient speech
language therapy for 3 months following a TBI that
h t i d f f ll i ti Sh t th she sustained from a fall in gymnastics. She met the
majority of her speech therapy goals targeting
cognitive skills within a structured therapy
environment and was therefore discharged from environment and was therefore discharged from
speech therapy with the recommendation that her
family contact SLP to resume therapy should deficits
become more noticeable once her skills were become more noticeable once her skills were
challenged in a more functional setting.
At the time of discharge, she exhibited mild executive
function and attention deficits. It was hoped that they p y
would resolve over time.
Anne cont
Once school started however Anne was unable to Once school started, however, Anne was unable to
keep up with the increased demands on her skills
and she exhibited poor performance in school. A
followup neuropsychological evaluation also follow-up neuropsychological evaluation also
revealed continued deficits that warranted speech
language intervention. Therefore, Anne was re-
referred to address continued deficits which referred to address continued deficits which
appeared to be due to lingering executive
functioning/attention deficits
E l ti i t d f t t d t d t h Evaluation consisted of parent, student, and teacher
interview forms from Dawson and Guares book,
Executive Skills in Children and Adolescents: A
P ti l G id t A t d I t ti Practical Guide to Assessment and Intervention
(2004)
Annes Evaluation Results
Mild deficits were noted in executive function skills and attention
Task initiation: Anne has trouble getting started on homework, knowing g g g
what to study, and procrastinates
Planning: has to be reminded of upcoming due dates so she doesnt
forget to complete assignments g p g
Working memory: trouble following directions, often has to make phone
calls to friends in order to get assignments or directions for
assignments, even when she had written down what she thought was g , g
adequate information to complete the assignment, often forgets where
she puts school materials and that she often loses things in her locker
Also demonstrated problems in attention, organization, time p , g ,
management and metacognition
Homework Planner
Annes Treatment
Treatment 1x per week focused on training in use of
compensatory strategies and in teaching Anne to complete her
work accurately
External aids and compensatory strategies (for binder and
planner at school) were developed and were implemented by
Anne, with monitoring/assistance as needed from her school
aide (private) (p )
A reinforcement (points system) with weekly goals was
developed during strategy training phase
Anne learned to utilized systems and strategies (with cues from
aide) Cues were gradually withdrawn and therapy was aide). Cues were gradually withdrawn and therapy was
discontinued with recommendation for aide to continue to assist
as necessary with use of positive reinforcement system and
weekly goals for Anne's improved independence.
Aid t it th l d d l Aide was to monitor these goals and develop new ones as
appropriate based on Anne's needs.
Annes Do It Right Strategies
DO IT RIGHT
(Accurate work the 1st time)
PAY ATENTION
Get away from distractions if possible (go to a quiet place to do
work, dont talk to others when working, ask that no one interrupt
you). Maybe go into hallway or other room when in Lions Den. y ) y g y
Leave others alone and stay on task until you are finished (Trial a
timer or other means of reinforcing staying on task)
Ignore others who are distractions to you (ex. Elana, Tori, Grace,
Michael))
Listen to teachers instructions
GET ORGANIZED
Put away anything that is not needed for this task
Get out all the materials you would need to finish the task Get out all the materials you would need to finish the task
Do It Right cont
KNOW WHAT YOU ARE SUPPOSED TO DO, BEFORE YOU
START
You should have accurate and complete You should have accurate and complete
information about the assignment in your
planner!!!!!!!
Read all directions before you start working and ead a d ecto s be o e you sta t o g a d
underline important information
Use organizational markings to help you
remember what you are supposed to do (ex. If you y pp ( y
are only supposed to do 1-10, make a line under
number 10 to remind you to stop, or if you are
supposed to all the odd numbers, circle them
before o start) before you start)
Do It Right cont
STAY ON TASK
Dont stop in the middle of work if you can help it, complete assignments
fully in one sitting
Have only one assignment out at a time Have only one assignment out at a time
Dont skip around in your work, stay on one assignment until the work is
done
Keep concentrating
DO ACCURATE WORK DO ACCURATE WORK
Work slowly, DO NOT RUSH
Work hard (concentrate, dont do sloppy work)
LOOK IT OVER to check your work (you will catch your mistakes)
STAY ORGANIZED STAY ORGANIZED
When finished with the assignment, put it away in the CORRECT FOLDER
Never stash something somewhere it does not belong
Annes Weekly Goals (Strategies)
1. Checkmark indicating completed HW (1pt
per day)
2 Accurate Bring Homelist (1 pt per day) 2. Accurate Bring Home list (1 pt per day)
3. Have all items on Bring Home list in bag
by end of day study hall (1 pt)
4. Clean out folders and file papers 1x per
week (5 points per week)
5 All assignments turned in for the week (10 5. All assignments turned in for the week (10
pts)
6. All papers in appropriate folders/files during
d h k (3 10 i h) random spot checks (3x: 10 points each)
Cognitive Rehabilitation- References
Kit Malia, B.Ed., MPhil, CPCRT and Anne Brannagan, DIPCOT, MSc. Materials and
resources available at http://www.lapublishing.com/tbi-cognitive-rehabilitation-therapy/
American Speech-Language-Hearing Association. (2003). Evaluating and Treating p g g g ( ) g g
Communication and Cognitive Disorders: Approaches to Referral and Collaboration for
Speech-Language Pathology and Clinical Neuropsychology [Technical Report].
American Speech-Language-Hearing Association. (2005). Knowledge and Skills Needed by
Speech-Language Pathologists Providing Services to Individuals With Cognitive-
C i ti Di d [K l d dSkill ] Communication Disorders [Knowledge and Skills].
American Speech-Language-Hearing Association. (2005). Roles of speech language
pathologists in the identification, diagnosis, and treatment of individuals with cognitive
communication disorders: Position statement. ASHA Supplement 25, in press.
Bernstein J H &Waber DP (1997) Pediatric neuropsychological assessment In T E Bernstein, J .H., & Waber, D.P. (1997). Pediatric neuropsychological assessment. In T. E.
Feinberg & M. Farah (Eds.), Behavioral neurology and neuropsychology (pp. 729736).
New York: McGraw-Hill.
Braunling-Mcmorrow, D., Dollinger, S. J ., Gould, M., Neumann, T., & Heiligenthal, R. (2010).
Outcomes of post-acute rehabilitation for persons with brain injury. Brain Injury., 24, 928- p p j y j y , ,
938.
Chapman SB. Neurocognitive stall: a paradox in long term recovery from pediatric brain
injury. Brain Injury Professional, 3(4): 10-13, 2007
Cicerone, K. D., Dahlberg, C., Malec, J . F., Langenbahn, D. M., Felicetti, T., Kneipp, S., et
al. (2005). Evidence-based cognitive rehabilitation: Updated review of the literature from
1998 through 2002. Archives of Physical Medicine and Rehabilitation, 86, 16811692.
Cognitive Rehabilitation- References
Cicerone KD, Langenbahn DM, Braden C, Malec J F, Kalmar K, Fraas M,
Felicetti T, Laatsch L, Harley J P, Bergquist T, Azulay J , Cantor J , Ashman T.
(2011) Evidence-based cognitive rehabilitation: updated review of the literature
from 2003 through 2008. Archives of Physical Medicine and Rehabilitation 92,
519-530.
Holmes, G. L., (1987). Diagnosis and management of seizures in children.
Philadelphia: Saunders p
Savage, RC. The Developing Brain after TBI: Predicting Long Term Deficits and
Services for Children, Adolescents and Young Adults. Brain Injury, 2009; 9.
Savage RC, DePompei R, Tyler J , Lash M. Pediatric traumatic brain injury: A
reviewof pertinent issues Pediatric Rehabilitation 2005;8(2):92-103 review of pertinent issues. Pediatric Rehabilitation 2005;8(2):92-103.
Sohlberg, M. M., Turkstra, L. , Optimizing Cognitive Rehabilitation: Effective
Instructional Methods, 1
st
Ed. 2011 Guilford Press, New York, NY.
Ylvisaker M, Adelson PD, Braga LW, Burnett SM, Glang A, Feeney T, et al.
Rehabilitation and ongoing support after pediatric TBI twenty years of progress.
The Journal of Head Trauma Rehabilitation 2005;20(1):95-109.
.Ylvisaker, M., Hanks, R., & J ohnson-Greene, D. (2003). Rehabilitation of
children and adults with cognitive-communication disorders after brain injury.
ASHA Supplement 23, 5972.

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