2/9/2012. Presentation Overview

(1)

Cognitive Rehabilitation of Children

and Adolescents:

Practical Strategies for the Home,

Community, and School Environments

CCHMC Outpatient NeuroRehabilitation Team (ONRT)

Stephanie Volker MS CCC-SLP

Director of the CCHMC Outpatient Neurorehabilitation Team (ONRT)

[email protected]

66th_{Annual OSLHA Convention}

March 9, 2012

Presentation Overview

• Basics about cognitive rehabilitation- efficacy,

what is it?, who does it?, who can benefit?

• Developing a process for cognitive rehab

Cognitive Rehabilitation- What will we

cover today?

Developing a process for cognitive rehab

• Components of a cognitive rehab approach

• Factors to consider in the pediatric population

• My approach for developing strategies (1-10)

• Case studies and practical strategies

Efficacy of Cognitive Rehabilitation

• There is substantial evidence to support interventions for

attention, memory, social communication skills, executive function, and for comprehensive-holistic neuropsychologic rehabilitation after TBI (Ciccerone, 2011)

• There is substantial evidence to support cognitive rehabilitation

Cognitive Rehabilitation- Does it work?

There is substantial evidence to support cognitive rehabilitation for people with TBI, including strategy training for mild memory impairment, strategy training for postacute attention deficits, and interventions for functional communication deficits. (Ciccerone, 2005)

• There is Level 2 evidence that behavioural and cognitive skills post ABI can be improved by participating in neurorehabilitation or neurobehavioural programs (Braunling-Mcmorrow et al., 2010).

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 rehabilitation and foster generalization to real-world tasks. (Ciccerone 2011)

Cognitive Rehabilitation- Does it work?

( )

• Self-directed strategy training is recommended for the 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 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)

A variety of professions including SLP’s

• ASHA has provided extensive recommendations and resources

for SLP’s who work with persons with cognitive-communication deficits

• SLP’s in any setting who treat those with cognitive deficits, not just SLP’s in medical settings

Cognitive Rehabilitation- Who Does It?

j g

• For kids and adolescents, the school IS an appropriate setting to do cognitive rehabilitation and school SLP’s should be doing it • Cognitive deficits have a significant impact on academic

success and the school setting is the optimal place to provide cognitive rehab

• School is their “real world”

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

Cognitive Rehabilitation- Who can benefit?

thinking/cognitive skills

• The 2

nd

_{description is broader and can include those}

with learning disabilities or a degenerative disease

process, in addition to those with an acquired brain

injury (thoughts??)

(2)

In the literature, there are a variety of definitions

or descriptions:

Summary:

• Targets improved measurable and satisfying

functional outcomes following neurological injury

• Targets recovery of cognitive deficits- directly

t i i

th

iti

th t h

b

Cognitive Rehabilitation- What is it?

retraining those cognitive processes that have been

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

In the literature, there are a variety of definitions

or descriptions:

Summary:

• Involves metacognitive training

• Consists of a variety of intervention strategies

d t

h i

(b th

d i di id

l)

Cognitive Rehabilitation- What is it?

and techniques (both group and individual)

• Highly individualized (patients and families

are involved in setting goals and measuring

outcomes)

• Can be provided by a variety of professionals

My Background

• 6 years OP rehab with

adults in acute care, IP

rehab, and OP rehab

O

• Over time I developed a

process (for a long time,

I didn’t even realize it

was a process)

Cognitive

Rehabilitation-How to Do It (My personal approach/philosophy)

• 10 years OP rehab with

children, adolescents &

young adults

• So fortunate to have

been able to specialize

in kids with ABI

was a process)

• Realized it when I

started to train

developmental

therapists re: how to

apply rehab techs.,

specifically strategy

development

Developing My Process

• I see client’s with acute injuries, “old injuries”,

learning disabilities

• Depending on the etiology of the deficit the

Cognitive

Rehabilitation-How to Do It (My personal approach/philosophy)

Depending on the etiology of the deficit, the

client’s background, the family’s experience

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 rehabilitation

U t ll d t ti i t ti ith l i

Cognitive

Rehabilitation-How to Do It (My personal approach/philosophy)

• Use a term called systematic instruction: persons with learning challenges (like ABI) benefit most from structured training that 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 continue to learn to become better at what we do.

Stay tuned……..

Key Points to Keep in Mind

Family support and

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

functions.

Cognitive

Rehabilitation-How to Do It (My personal approach/philosophy)

• Goal’s must be

functional and SMART*

• Highly individualized

• Family support and

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

(3)

Cognitive Rehabilitation Targets Improved

Functional Outcomes

Extensive patient/family education

Stimulation for recovery of underlying skills

Development/training for compensatory strategies

Cognitive

Rehabilitation-How to Do It (My personal approach/philosophy)

Education

Stimulation Strategies

Cognitive Rehabilitation Therapy (CRT)

Cognitive Rehabilitation- Malia and Brannagan

Process Training Education Strategy Training Functional Activities Training

Malia, Brannagan

Volker

Education

Cognitive

Rehabilitation-How to Do It (My personal approach/philosophy)

Process Training Education Strategy Training Functional Activities Training Stimulation Strategies

Education- Therapist is a Teacher

• the neuroanatomy of the

brain, physiology, mechanics of injury to the brain • Role of insight into problems

• Emotional consequences of an ABI

• Coping skills

Cognitive Rehabilitation: Education –

Malia and Brannagan

1

st

_{provide GENERAL education}

2

d

_P

_{id SPECIFIC}

g p

and how insight is impacted after an ABI

• Patterns of recovery from ABI

• The process and 4 parts of CRT

• Cognitive functions and how they are impacted in ABI

2

nd

_{Provide SPECIFIC}

education

• The client’s deficits and

impact on his/her life

Process Training

• An analysis identifies

the deficient underlying

key cognitive processes

• Training exercises are

designed to improve a

• With correct kind of

stimulation, new neurons

can create optimal neural

pathways and templates

• “Cells that fire together

Cognitive Rehabilitation: Process Training –

Malia and Brannagan

designed to improve a

particular deficit

• Exercises usually

involved pen/paper,

remedial games,

computer tasks

• Cells that fire together,

wire together”

• A direct retraining of

cognitive processes can

result in reorganization of

higher level thought

processes

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 veterans with mild, moderate and severe traumatic brain injury (TBI), post concussion syndrome and other neurological disorders.

Cognitive Rehabilitation: Process Training –

Example

y g

• The Pay Attention Program by Thomson and Kerns is based on the APT 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

• 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/

(4)

Strategy Training

• Strategies are taught to

compensate for deficits

• Complementary to the

process training since if

• This is not an easy

option, whole books

have been written about

this process

Cognitive Rehabilitation: Strategy Training –

Malia and Brannagan

p

g

a deficit does not

improve, strategy

training aims to teach

the person how to

bypass the problem

• The problem is still

there, but the functional

impact of it is minimized

• Ex. IP rehab “give them

a memory notebook”

• Takes a long time

• Not everyone can

benefit from, or use

strategies

Strategy Training

3 categories of strategies

Environmental Strategies (accommodations)

• those which the individual does not have to take any responsibility

t i ll d ith l i j d ti t

Cognitive Rehabilitation: Strategy Training –

Malia and Brannagan

• typically used with severely injured patients. • Altering the environment around the individual External Strategies (strategies)

• The person relies on others, physical objects, or devices. • 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 person’s head • Ex. visualization, association, mnemonics, retracing

• Good insight/awareness, is the key to successful use

of strategies

• Building metacognition is a crucial step in therapy

Cognitive Rehabilitation: Strategy Training –

Malia and Brannagan

Successful Strategy Training:

Insight and Practice

• 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

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.

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

Cognitive Rehabilitation: Functional Activities

Training – Malia and Brannagan

• Any activity has the potential to be used to treat a

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

• OT’s may be more adept at using this technique than

SLP’s, but they shouldn’t be

Malia, Brannagan

Volker

Education

Cognitive

Rehabilitation-How to Do It (My personal approach/philosophy)

Process Training Education Strategy Training Functional Activities Training Stimulation Strategies

Children and adolescents who have

sustained an acquired brain injury (ABI)

• Traumatic brain injury • Hemorrhages

(inter-cerebral, intra-cranial, subarachnoid) due to

• Metabolic encephalopathy • Brain tumor resection

Ab i iti

Cognitive Rehabilitation- Who can benefit?

subarachnoid) due to aneurysm or AVM • CVA (stroke) • Infection: meningitis, encephalitis, cerebritis • Anoxia/hypoxia • Toxic encephalopathy (drug overdose) • Abscess or sinusitis • Seizure disorder • Seizure focus resection • Hemispherectomy for

control of seizures • Progressive neurological

(5)

Factors which impact recovery in pediatric

brain injury

• Predicting recovery and long-term outcome following

a brain injury is a complicated process, dependent on

a number of factors, including:

L th f ti l d i i j (h b tt id ft

Cognitive

Rehabilitation-Application to the Pediatric Population

– Length of time elapsed since injury (have a better idea after one year what the outcome will be)

– Premorbid language/cognitive abilities – Family support

– Neurological damage sustained

– The age of the child at time of injury: Damage to a still

developing brain

– Change in symptoms over time and ability to

compensate

Neurological factors

• 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

Cognitive

Rehabilitation-Application to the Pediatric Population

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 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

• 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

later in life

Cognitive

Rehabilitation-Application to the Pediatric Population

• The conventional thinking regarding TBI in young

people was that the child’s 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”

– “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. • ABI can have a negative impact on continued brain maturation

Cognitive

Rehabilitation-Application to the Pediatric Population

g p

and development in young people as they get older and grow 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 • 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 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 brain recovery

• Neuro-cognitive stall as defined by Chapman (2007) is a halting

Cognitive

Rehabilitation-Application to the Pediatric Population

Neuro cognitive stall as defined by Chapman (2007) is a halting or slowing in later stages of cognition, social, and motor 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 not meet later developmental milestones

• This neuro-cognitive stall may emerge despite the individual seeming to have recovered cognitive abilities commensurate to one’s pre-injury level

Cognitive

Rehabilitation-Application to the Pediatric Population

(6)

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." • Shawna was a nine-year-old third

Cognitive

Rehabilitation-Application to the Pediatric Population

y grader when she fell off a two-story balcony and sustained a severe 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. 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 • Peter sustained a moderate TBI

in a motor vehicle/bicycle

Cognitive

Rehabilitation-Application to the Pediatric Population

in a motor vehicle/bicycle accident as a seven-year-old 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 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 • As young people’s brains develop, the world around them also

becomes more complex and sophisticated. Learning in school

Cognitive

Rehabilitation-Application to the Pediatric Population

p p g

becomes more difficult, social and behavioral expectations 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”.

• 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”

Changes in Educational Demands

GRADE 4 READING TO LEARN GRADE 1 LEARNING TO LEARN & READ

Holmes, 1987

Cognitive

Rehabilitation-Application to the Pediatric Population

34

GRADE 4 READING TO LEARN

MIDDLE SCHOOL LEARNING TO ORGANIZE YOUR LEARNING HIGH SCHOOL

LEARNING TO LEARN, READ, & ORGANIZE ON YOUR OWN

Changes in Educational Demands

• 1ST GRADE

• Learning to learn • Learning to read • Regulating behavior

• Attention, emotional and behavioral control • Structure and support

• Low content • 4TH GRADE

• 7TH GRADE

• 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 and teachers

• Increased need for organization within the learning experience

Cognitive

Rehabilitation-Application to the Pediatric Population

35

• Increase in quantity, depth and complexity of academic material

• Decrease in contextual support • 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 • Increased demand for speed • Increased demand for writing

• Need for more self-direction and self-initiation • Major developmental changes (physiological,

psychological, cognitive) • Increased peer demands • Increased demand for speed • HIGH SCHOOL

• Further increases in quantity, depth and complexity of academic material • Further increases in complexity of psychosocial

relationships

• Continuing decrease in contextual support • Maximum demands on organization and speed

O

UNT

context

Cognitive

Rehabilitation-Application to the Pediatric Population

Context Content Interaction

36 AM

O

1

st

₄

th

₇

th

₉

th

content

GRADE

Bernstein & Waber, 1990

(7)

Optimal Context Content Interaction

for ABI Patients

O

UNT

Cognitive

Rehabilitation-Application to the Pediatric Population

AM

O

1

st

₄

th

₇

th

9

th

GRADE

context

content

Treatment for “life”…….

• 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

l

t

ff

t

f ABI

l

th t

Cognitive

Rehabilitation-Application to the Pediatric Population

long term effects of ABI on young people so that

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

for cognitive rehabilitation may not fit the traditional

model of therapy services

• In our program, we use a variety of models such as a

h

i

f

lt ti

b

t/i t

i

Cognitive

Rehabilitation-Application to the Pediatric Population

changing frequency, consultative, burst/intensive,

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 skills impacted by an ABI

• Orientation

• Attention

• Memory

• Problem Solving

Cognitive Rehabilitation- What do you treat?

Problem Solving

• Social Skills

• Reasoning

• Executive Functions

• Processing

• Insight/Awareness

Cognitive Rehabilitation Targets Improved

Functional Outcomes

Extensive patient/family education

Stimulation for recovery of underlying skills

Development/training for compensatory strategies

Cognitive

Rehabilitation-How to Do It (My personal approach/philosophy)

Education

Stimulation Strategies

Developing and Training in the Use of

Strategies and Accommodations

HOW DO YOU KNOW

WHEN TO BEGIN??

• Need to consider the etiology of the deficit and time since onset • Potential for further skill

Cognitive Rehabilitation- Strategy Development

WHEN TO BEGIN??

improvement

• Functional impact of the deficit (can you make an impact right away with strategies?)

• Motivation/comfort level of patient/family

(8)

Process for Developing Strategies for

Functional Independence

1. Determine a functional outcome goal

2. Determine the deficits contributing to poor outcome

Cognitive Rehabilitation- Strategy Development

Process

g

p

3. Educate patient/family re: deficit and goal

4. Probe patient’s insight/awareness of impact of deficit

and target this in therapy as needed (metacognition)

5. Develop a strategy/accommodation to achieve

functional goal

Process for Developing Strategies for

Functional Independence

6. Target the strategy in therapy to train the client in

use

7 T i th

i

d

t

Cognitive Rehabilitation- Strategy Development

Process

7. Train the caregivers and support system

8. Develop reinforcement system to help generalize to

functional tasks

9. Target generalization of strategy to functional tasks

10. Once a strategy/step is mastered move on to the

next one

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

• Examples:

Cognitive Rehabilitation- Strategy Development

Process: Outcome Goal

p

• Teacher would like child to complete in class work 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 for Developing Strategies for

Functional Independence

1. Determine a functional outcome goal 2. Determine the deficits

contributing to poor outcome

6. Target the strategy in therapy to train the client in use 7. Train the caregivers and

support system

Cognitive Rehabilitation- Strategy Development

Process

3. Educate patient/family re: deficit and goal 4. Probe patient’s

insight/awareness of impact of deficit and target this in therapy as needed (metacognition) 5. Develop a

strategy/accommodation to achieve functional goal

8. Develop reinforcement system to help generalize to functional tasks

9. Target generalization of strategy to functional tasks 10. Once a strategy/step is

mastered move on to the next one

Determine Which Deficits Contribute

You can do this by:

• Reviewing assessment results (standardized

assessment)

Observe patient in functional tasks or ask them to

Cognitive Rehabilitation- Strategy Development:

Determine Deficits

• Observe patient in functional tasks or ask them to

complete specific tasks designed to tease out

deficits

• May need patient/family to keep data

• Ask specific questions designed to break down task

into components and determine what the deficits

are (interview skills)

Sample Interview Questions: Attention

• Do you ever feel as if you have trouble paying

attention/concentrating? • Do you notice that you are

easily distracted?

Wh t t f thi b th

• Is he/she able to stay on task to finish a job (dressing, HW, etc.) • How long can he/she stay on

task?

• Are there differences in

tt ti d di th ti

Cognitive Rehabilitation- Strategy Development:

Determine Deficits

• What types of things bother you when you are doing HW? • 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”? • Do you lose your place if you

have to pay attention to something else? • How much work can you do

before you lose focus?

attention depending on the time of day, environment, mood? • What do you need to do in order

to get his/her attention? • Can you talk to her while she is

doing something else? • What “tricks” have you tried to

get his attention? • What are his big distractions? • How much cueing does he need

(9)

Example for Determining Deficits

Teacher would like child to complete in class

work independently.

Child cannot complete work independently

b

Cognitive Rehabilitation- Strategy Development:

Determine Deficits

49 because….

• did not attend to the directions and/or could not

process them

• loses focus and attention and gets off task

(internal or external distractions?)

• unable to remember all the steps

• unable to problem solve through tasks

Example for Determining Deficits

Adolescent would like to be able to work the

cash register at her fast food job. She

cannot because….

Cognitive Rehabilitation- Strategy Development:

Determine Deficits

50 – she can’t keep up with speed of

information being said to her at the register

– can’t remember what it is she is supposed

to get once she leaves the register

– gets too distracted by noise that she is

unable to focus on the task

Clinical Reasoning

• We need to be “detectives” and use the

combination of knowledge of neuroanatomy

and physiology, past experience, education of

pt./family and good interview skills to gain

Cognitive Rehabilitation- Strategy Development:

Determine Deficits

p / a

y a d good

e

s

s o ga

information from patient/caregiver, team

member report, observation in functional

activities, data collected from well-designed

tasks to control for variables, literature and

best practices

• CLINICAL REASONING IS CRUCIAL

Clinical Reasoning

“He can’t follow directions”

Attention: Did he pay attention? Will he maintain focus to complete?

Processing: Was the information too much or too fast?

Cognitive Rehabilitation- Strategy Development:

Determine Deficits

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 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 for Developing Strategies for

Functional Independence

support system

Cognitive Rehabilitation- Strategy Development

Process

Educate patient/family re: deficit and goal

• Once you have determined the skills which need to

be targeted (for recovery or for development of

Cognitive Rehabilitation- Strategy Development:

Education

compensatory strategies) EDUCATION is involved in

every session, every task, every discussion

• Education is the key to improving metacognitive

awareness and thereby developing and successfully

applying strategies

(10)

Educate patient/family re: deficit and goal

Keys to successful education:

• Knowing how much information to give

• Taking into account the acceptance level and

i

l

f h

i

/f

il

Cognitive Rehabilitation- Strategy Development:

Education

emotional status of the patient/family

• 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)

• Use “teaching moments”

• Active learning (patient writing)

• Ask “what do you know?” (attention ex.)

Kinds of Attention

FOCUS

Able to pay attention and concentrate

KEEPING FOCUS

Able to keep paying attention and focus as it takes to do the work

Cognitive Rehabilitation- Strategy Development:

Education

BLINDER FOCUS

Keep focus even when there are distractions around. Put on the blinders and block it

all out.

Educate patient/family re: deficit and goal

If the patient/family is not ready to benefit from

education provided, you can:

Cognitive Rehabilitation- Strategy Development:

Education

• 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 for Developing Strategies for

Functional Independence

support system

Cognitive Rehabilitation- Strategy Development

Process

Determine Patient’s

Insight/Awareness and Target as Needed

• Remember good

insight/awareness/metacognition is the key to

successful strategy use

Cognitive Rehabilitation- Strategy Development:

Metacognition

gy

• You may need to stay at this point for a while

before moving on to developing strategies

• There are different levels of

awareness/insight

• How can you improve metacognition?

Probe Patient’s Insight/Awareness and

Target as Needed

• Use pre-post self-assessments for tasks targeting

skill

• Use self-evaluation forms and solicit feedback

f

Cognitive Rehabilitation- Strategy Development:

Metacognition

from other sources

• Have patient keep a journal

• Have others “gently” point out occurrences when

deficit impacts in real life

• Complete tasks in therapy and discuss patient’s

performance: then link to real world outcomes of

same level of performance

(11)

Improving Metacognitive Awareness with

Specific Tasks

Client predicts how well he/she will do

th t k

Client completes the excercise

Client and therapist independently rate how well he/she thinks the client has

Cognitive Rehabilitation- Strategy Development:

Metacognition

on the task thinks the client has done on the task

Client and therapist discuss the similarities and differences in the ratings Education provided as needed regarding the skills which were noted to be deficient in the task

Therapist and client discuss how the performance on the

task could be improved

Improving Metacognition and Introducing

Strategies

Client predicts how well he/she will do

on the task

Client completes the exercise

Client and therapist independently rate how well he/she thinks the client has

done on the task

Client and therapist discuss the similarities and differences in the ratings

Cognitive Rehabilitation- Strategy Development:

Metacognition

Education provided as needed regarding the skills which were noted to be deficient in the task

Therapist and client discuss how the performance on the

task could be improved

Therapist and client develop specific

strategy(s) to improve the performance

Client completes the 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

Can you improve metacognition in younger kids?

YES!!

Process (Using interrupting as an example)

1. Describe the deficit in language they understand (“jump in”, “rudey”)

2 Observe them and take a baseline of how often it occurred in a

Cognitive Rehabilitation- Strategy Development:

Metacognition

2. Observe them and take a baseline of how often it occurred in a task and provide them a visual representation (I use 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

Case Study: Brandy

• Brandy is a 16 year old girl who sustained a TBI in an MVA July 2011.

• Documented injuries include subcortical hemorrhagic contusions of the parietal and frontal lobes

• Spent 24 days in IP rehab, discharged and referred to OP rehab

Cognitive Rehabilitation- Strategy Development:

Metacognition

p y g

at Cincinnati Children's Outpatient Neurorehabilitation Team • 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 frequent school absences

• Brandy/family did not pursue OP therapy until November 2011

Case Study: Brandy

• 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

• IE: mild decrease in AC, VE, RC, WE, moderate decrease in

Cognitive Rehabilitation- Strategy Development:

Metacognition

attention, processing speed, memory, impulse control and a reduced frustration tolerance

• Initial sessions spent providing lots of education re: TBI, expected deficits associated with her injuries, probing functional 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 in” to what I was “selling”

Case Study: Brandy

• In 3rd_{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 to tally how many times her attention wandered during that task in 10 minutes- she stopped at 30

Cognitive Rehabilitation- Strategy Development

pp

• I also started to point out when she got the “spacey look” (her 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 5th_{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

(12)

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

Cognitive Rehabilitation- Strategy Development:

Metacognition

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

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 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

Cognitive Rehabilitation- Strategy Development:

Metacognition

still need to be addressed in therapy. This is not intended to be a negative tool, but rather one that points out Brandy’s progress, and areas that are still seen as problems by others, of which she may be unaware. Brandy chose the 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.

Always Often Sometime Rarely Never

3. Acts impulsively (without thinking ahead or thinking through something fully)

Always Often Sometime Rarely Never

Insight Building with Rating Scale: Brandy

• By the 10th_{session, Brandy agreed to fill out the rating scale and}

provide it to friends and family

• She endorsed functional impact of memory problems with “sometimes” or “often” ratings on 8/10 questions (family/friends were commensurate)

Sh t d th t h lf ti h d i ifi tl i

Cognitive Rehabilitation- Strategy Development:

Metacognition

• 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 easily and to act impulsively

• She was not aware of her tendency to misunderstand conversations and make mistakes when re-telling stories • This lead to development of strategies for improved comprehension

and retention of conversations

Process for Developing Strategies for

Functional Independence

support system

Cognitive Rehabilitation- Strategy Development

Process

Develop a strategy/accommodation to

achieve functional goal

Cognitive Rehabilitation- Strategy Development

ALWAYS involve the patient/ family in developing possible t t i strategies 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

• As a clinician, you should have a “bag of

tricks” to pull from

• Resources: books continuing ed “how to

Cognitive Rehabilitation- Strategy Development

Resources: books, continuing ed, how to

books”, other populations (ADD, tourette’s)

• Other patients, teachers, colleagues, parents

• Have suggestions ready but be open to ideas

from patients and caregivers

• I have gotten great ideas from them!

(13)

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

Cognitive Rehabilitation- Strategy Development

functional impact, the “annoyance” factor, possible

strategies

• Have them “name” the strategy to make it personal

• Have them create a written or picture description of

the strategy

• I have all of my kids keep a “strategy” notebook

which they manage, make, and keep

Amy: Making sure “I got it”

“Say What?”

Ask others to

repeat

information

Cognitive Rehabilitation- Strategy Development

“Put the Breaks

On!”

Ask others to slow

down when they are

talking too fast

Check It!

Re-tell the

information

to verify I

got it

DARAH’S GOOD

LISTENING

Cognitive Rehabilitation- Strategy Development

GET THE JOB DONE

• What I am supposed

to be doing?

• Do I have everything I

need?

• Start to work

• Pay attention

• No la la land

• Block out distractions

Cognitive Rehabilitation- Strategy Development

76 • Don’t talk about

things that “pop in my

head”

• Keep going until it’s

done

JOB STOPPER

Cognitive Rehabilitation- Strategy Development

JOB STOPPER

: USES DISTRACTIONS TO STOP YOU FROM

DOING A JOB WELL OR FINISHING A JOB. HE TAKES AWAY YOUR

ATTENTION.

USE

FOCUS MAN

TO BLOCK THE JOB STOPPERS AND GET THE

JOB DONE

Cognitive Rehabilitation- Strategy Development

(14)

My JOB STOPPERS

TOYS

TV

Cognitive Rehabilitation- Strategy Development

PEOPLE

WHISKERS

ME

Area of Challenge Possible Outcomes What I can do/Strategies Math •Don’t understand what the teachers

talking about.

•Won’t 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

•Use the How To Overcome Writers Block paper

•Hamburger Strategy

Ally’s Tools for Success

Cognitive Rehabilitation- Strategy Development

•Awkward wording •Misspelling words

g gy •Somebody/someone check the paper for me

•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 I’m thinking in my brain •I feel stupid/ •People find it difficult to talk to me

•Mentioning that I struggle with word finding out loud •Pause

•Rewording/using alternate words Reading Comprehension •Not understanding what I’m reading

•Have to read things sometimes two to three times to understand it

•Re-read material •Use Sparknotes to help •Outline •Read aloud •Books on tape

BED TIME ROUTINE

1. GO POTTY

2. TAKE BATH

3. PUT ON PJ’S

Cognitive Rehabilitation- Strategy Development

J

4. BRUSH TEETH

5. BOOK TIME

6. PRAYERS/BED

DISTRACTIONS

Cognitive Rehabilitation- Strategy Development

Examples of Strategies and

Accommodations

Goal: Adolescent wants to work cash register at

her fast food job

• Girl verbally repeats every item as customer

orders as she puts it into register asks for repeat

Cognitive Rehabilitation- Strategy Development

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…)

(Patient strategy)

• Girl is able to work register only in low volume

times when only her register is open to decrease

distractions (Accommodation)

Examples of Strategies and

Accommodations: Brandy

Attention strategies/accommodations

• moved to front in all classes

• asked friends not to talk with her in class

Cognitive Rehabilitation- Strategy Development

• began to use Smart Pen- Live Scribe for note

taking (www.livescribe.com)

• “force field focus” to block distractions

• “snap” back to focus

• honest with friends when she could not focus

on a conversation/story

(15)

Examples of Strategies and

Accommodations: Brandy

Memory strategies/accommodations

• “Active Encoding” purposefully put into memory

• Cell phone “home” in each room (decreased losing

cell phone from 10x per day to 1x in a week, in only

Cognitive Rehabilitation- Strategy Development

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

short time

• Videotaping cheer practice

Process for Developing Strategies for

Functional Independence

support system

Cognitive Rehabilitation- Strategy Development

Process

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

increasingly complex tasks

Cognitive Rehabilitation- Strategy Training

increasingly complex tasks

Verbally describe strategy

Demonstrate use with minimal cues in a structured therapy task Initiate use in functional tasks with minimal reminders

Learning Strategies

Therapist provides education re: the

underlying skill deficit

Strategy Developed Client completes a task which targets use of the strategy

Cognitive Rehabilitation- Strategy Training

deficit

Use of strategy (s) is targeted, measured,

and cued in hierarchical fashion

Client gains practice in use of strategy in

tasks

Increase difficulty of 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

• Whole books have been written about how to

Cognitive Rehabilitation- Strategy Training

Whole books have been written about how to

train, what data to keep, when to move up

• I like to introduce strategies in the context of

games or fun activities so the kids see benefit

and get motivated

• I like to use “real life” tasks such as school

and homework

Process for Developing Strategies for

Functional Independence

support system

Cognitive Rehabilitation- Strategy Development

Process

(16)

Train the caregivers and support system

• The parent/caregiver(s) should already be familiar

with the strategy since they helped develop it

• Parent/caregiver should be observing (not

necessarily in room) as the child/adolescent is trained

i

Cognitive Rehabilitation- Training the

Support System

in use

• They will need training in appropriate cues, hierarchy

of application (set goals)

• Education for school personnel: background

information, description of deficits, examples of how

deficits could impact school, suggested strategies,

cues and plan if already developed

• Consistent use and cues is KEY!!!!!

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)

Cognitive Rehabilitation- Training the

Support System

doing something else)

2. Speed of processing information/shifting attention

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/Listening Strategies

Handout Provided to Parents/School

• However, we know that once you have his

attention, he IS able to listen, pay attention,

and remember information. The key is getting

Cognitive Rehabilitation- Training the

Support System

y

g

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.

Attention/Listening Strategies

Handout Provided to Parents/School

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

attention

Cognitive Rehabilitation- Training the

Support System

– He should turn his eyes to you and fold hands together – 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

– 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

Attention/Listening Strategies

Handout Provided to Parents/School

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?

– 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?

Cognitive Rehabilitation- Training the

Support System

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

our shoes on or we won’t be able to leave on time. Go get your shoes right now so we won’t 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.

Education for school personnel: Example

• Joshua is a 14 year old s/p meningitis who demonstrated mild-moderate deficits in processing speed, memory, and reading comprehension.

• These deficits greatly impacted him in the school environment and he felt very overwhelmed by teachers’ expectations

• His mother reported difficulty getting Joshua to communicate his

Cognitive Rehabilitation- Training the

Support System

s o e epo ed d cu y ge g Jos ua o co u ca e s feelings to teachers and a feeling that the teachers “just don’t get it” • 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 Joshua’s ratings 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

(17)

The Understanding Scale

“Joshua 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

comprehension/understanding of material he is taught. This can

Cognitive Rehabilitation- Training the

Support System

also help his teachers monitor his understanding and learning of material in light of all of his challenge areas. Using this scale, Joshua 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 example of this is provided as an attachment.”

The Understanding Scale

** This scale was developed by a therapist at CCHMC Outpatient

Neurorehabilitation Team. We use this in therapy and thought it might be useful in other settings as well.

**Joshua 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:

Cognitive Rehabilitation- Training the

Support System

• Joshua 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. • Joshua 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 Joshua increase his own awareness of what he does and does not understand well.

• Teachers/tutors/support personnel can use this rating to provide feedback to Joshua about his understanding.

The Understanding Scale

1. Joshua 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 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. Joshua 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 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 h f l if h d t d b t h lf f th i f ti h h d/l d d 50% f it

Cognitive Rehabilitation- Training

the Support System

3. Joshua 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 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. Joshua 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. Joshua 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 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.