Learning Objectives THE ESSENTIAL BRAIN INJURY GUIDE. CBIS Exam Prep Course Section 4 10/27/2016. Rainbow Rehab Centers 1. Cognitive Impairments

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1 THE ESSENTIAL BRAIN INJURY GUIDE Neurocognitive Issues Section 4 Cognitive Complications Janice White PhD CBIST Rainbow Rehab Centers Chapter 10 Learning Objectives Gain an understanding of the concepts involved in cognitive rehabilitation Be able to describe the types of deficits in attention frequently observed in persons who have sustained a brain injury Over 5 million Americans experience disabilities due to brain injury Be able to articulate the type of damage sustained by TBI that results in delays in information processing Be familiar with the 5 subtypes of attention Be able to explain factors that interfere with cognitive rehabilitation Be able to distinguish between the 4 types of memory Long-term care and supervision may be required for persons with brain injury due to cognitive and communication dysfunction, leading to increased caregiver burden and cost of care Cognitive Impairments Include difficulties with: Attention Memory Problem-solving Decision-making.. Cognitive Impairments can Impact: Level of independence Educational or vocational engagement Social interaction Family interaction Life satisfaction.. and other areas of cognition that can impact a person s ability to successfully participate in activities of daily living Remediation can improve a person s ability to engage in social interactions, recreation, and productive activities like work and school Rainbow Rehab Centers 1

2 What is Cognition? It is a complex collection of conscious mental activities, such as attention, perception, comprehension, remembering, or using language Alertness Association Attention Attention Span Awareness Categorizing Cognitive Skills and Processes Comprehension Decision-making Insight Learning Maintenance of sequential goaldirected with self-correction It is a process by which sensory input is transformed reduced, elaborated, recovered and used Maintenance of temporal order of stimuli Memory Organizing Planning Problem-solving Reasoning Retention Selective Attention Stimuli Recognition Stimuli Discrimination Synthesis of Information Thinking Cognitive Skills and Processes Identified by ASHA and ACRM. Fundamental cognitive processes, such as sensory perception, attention, information processing and memory underlie more complex cognitive processes, like categorization, problem solving, reasoning, and abstract thought Retraining of fundamental cognitive processes can result in reorganization of higher level or more complex cognitive processes For example damage to the attention network of the brain will affect attention and also memory functions Domains of Cognitive Functioning Categorization ATTENTION ALTERNATING SELECTIVE SUSTAINED FOCUSED DIVIDED These subtypes of attention are viewed in levels. Because we do not have unlimited processing resources, attention helps us to best allocate these resources Attention One of the most fundamental cognitive skill sets Influences all other cognitive skills Deficits in this area are common after brain injury Subtypes of Attention Focused Attention Sustained Attention Selective Attention Alternating Attention Divided Attention Descriptions Selecting one source of information (i.e., stimulus) while withholding responses to irrelevant stimuli Maintaining attention to complete a task accurately and efficiently over a period of time Maintaining attention in the presence of distractions Shifting between tasks that demand different al or cognitive skills Requires the ability to respond simultaneously to multiple task demands while maintaining speed and accuracy Examples Responding to pain; Turning to see a loud sound behind you Reading a book; Watching a TV show; Listening to a presentation Focusing on the presenter at a conference while ignoring others talking outside; Studying while music is playing Reading a recipe and stirring a pot; Filing and answering the phone Driving and talking on the phone; Cooking multiple courses at the same time Rainbow Rehab Centers 2

3 Deficits of Attention Attention Process Training Program (APT) Rehabilitation interventions for attention deficits vary as a function of the component of attention or the system to be targeted Interventions can include a focus on sharpening the skill with distracters present, as well as training a person with a brain injury to recognize what distracts them and then look for ways to minimize the distractions Retraining systematically increases the level of distracters in an environment to simulate high-level demands A process-specific approach to Cognitive Rehabilitation Hierarchically organized by difficulty Persons progress to a higher level when the easier task is mastered Begins with sustained attention tasks and progresses to selective, alternating, and divided attention Shown to result in improved memory performance in persons with brain injuries Categorization Deficits in categorization can interfere with: The initiation and performance of ADLs The acquisition, processing, and learning of new information Successful problem solving and decision-making CATEGORIZATION Categorization skills are important in: Speed of processing Problem solving Other higher order cognitive processes (e.g., decision-making) Individuals with brain injuries tend to base decisions about category membership according to a single attribute and have difficulty responding to more complex and multidimensional stimuli The Categorization Program Therapeutic approach aimed at remediating deficits In object categorization In decision-making Categorization Program Tasks Begins with basic attribute identification and extraction Progresses to higher level concept formation and rule-based decision making CATEGORIZATION Remediation MEMORY 10/27/2016 Rainbow Rehab Centers 3

4 Memory Memory impairments can arise from difficulty in the encoding, storage or retrieval of information Taste Hearing Touch Vision Smell Memory Processes Rehearsal Memory Sensory Memory Short Term Memory Working Memory Long Term Memory Retrieval Where perceived information is put in a context that can be stored Stabilization of a memory The search for a memory or activation of a memory Holds sensory information for a few seconds after perception Enables recall of information lasting a few minutes to hours Temporary storage and active processing of information Permanent consolidation and storage of information Sensory Memory Short Term & Working Memory Holds information from the senses for a few seconds immediately after the item is perceived There are five sensory memory senses Short Term Memory Enables recall of information that lasts a few minutes to hours Example: the color of a car that just passed you Working Memory Is a central cognitive process responsible for the temporary storage and active processing of information Example: calculating change in your head Short term and working memory can be distinguished because short term memory passively holds information while working memory actively processes it Long Term Memory Involves permanent consolidation and storage of information, often lasting a lifetime Long Term Memory Implicit Memory It is divided into explicit and implicit memory Implicit memory comes in the form of procedural and cognitive skill memory Procedural memory allows people to remember how to tie their shoes or ride a bike without consciously thinking about it (i.e. muscle memory) Cognitive skill memory is for procedures necessary to win a game or solve a problem Rainbow Rehab Centers 4

5 Long Term Memory Explicit Memory Explicit memory is information that can be consciously declared and is known as semantic memory or episodic memory Semantic memory includes general knowledge or facts about the world Episodic memory includes personal, autobiographical recollections of experiences PROCESSING SPEED Processing Speed Cognitive reaction time, or the time it takes a person to gather the information presented, process it, and respond When impaired, the rate at which new information can be attended to and later recalled is also impaired Must be targeted across all cognitive skills EXECUTIVE FUNCTIONS Executive Functions Injury can result in problems with: Abstract thought Move freely from one activity to another; Consider more than one solution when problem solving Create useful strategy for functional use Hold info in mind to complete task; Update & manipulate info Age appropriate insight of strengths & weaknesses Executive functions are? Analyzing all aspects of a situation Complex cognitive processes that involve reasoning, planning, judgment, initiation and abstract thinking Considering all potential solutions to a problem Executing those solutions Maintaining cognitive flexibility if one solution does not work Self-monitoring Impulse control; Manage distractions; Delay responses Independently assess ; Respond to and make changes as needed Spontaneous planning of new tasks; Anticipate future events; Prioritize Intermediate and long term goal setting, appropriate to ability Independently initiate new activity; Seek and search for new information; Persist; Conceive new ideas Rainbow Rehab Centers 5

6 Executive Skills Individuals with executive functioning deficits often exhibit: Impulsivity Disinhibition Hyper-verbosity Poor control of emotions Cognitive Rehabilitation approaches include teaching individuals to use formal problem solving strategies, which include: Approaching novel situations in a systematic manner Analyzing problems Considering alternative solutions Prioritizing solutions Reviewing the outcomes METACOGNITION Metacognition Metacognition is a higher-order, self-regulatory function that includes awareness of one s own cognitive processing There are three levels of impairment in metacognition: Awareness of deficits caused by the injury For example, memory deficits, delays processing speed Awareness of the functional implications of these deficits Awareness to set realistic goals Metacognition & Executive Function Metacognition is conceptualized as a higher order, self-reflective, cognitive function It has an integrative role for other areas of executive functioning (e.g., self-monitoring and information processing) Executive functioning and metacognition are not the same processes Executive functioning and metacognition do depend on each other for example An individual can be aware of the struggles they are having with problem solving (intact metacognition), however they may be unable to successfully solve problems (deficit in executive function) Executive functions have been conceptualized as cognitive directors since they assist in the interaction between other cognitive processes, such as memory, attention and perception Metacognitive functions can similarly be viewed as awareness directors since they oversee the thinking processes, allowing knowledge of thinking about thinking Metacognition Anosognosia Diminished self-awareness and failure to recognize a personal disability Reductions in self-awareness can have important consequences for outcomes, including: Compliance with rehabilitation Ability to return to independent living Metacognitive Strategy Training Used to enhance an individual s ability to internalize awareness and control over s The primary goal of metacognitive strategy training is to enhance a person s ability to internalize awareness and control over their Cognitive function is widely distributed across many regions and structures of the brain Frontal Systems Temporal Systems Limbic Systems Parietal Systems Occipital Systems COGNITIVE FUNCTION Rainbow Rehab Centers 6

7 Frontal Lobe Emotional control al control Verbal expression Problem Solving Decision Making Social control Motivation Attention Parietal Lobe Tactile performance Spatial orientation Academic skills Object naming Visual attention Eye hand coordination Occipital Lobe Visual stimuli processing Factors that Interfere with cognitive function following a brain injury Hearing An estimated 44% for non-blast injuries and 62% in blast related injuries Hearing loss contributes to confusion and deficits in attention and memory Vision Prone or susceptible to dysfunction and important to assess Memory Face recognition Selective attention Locating objects Temporal Lobe Object categorization Receptive language Emotional responses Language comprehension Cognitive functions by location It is important to consider that such skills in reality are not so discretely defined, as there are innumerable connections between lobes and brain regions. Common Factors that Interfere with Cognitive Function Following a Brain Injury: Communicative Functions Expressive aphasia Refers to the ability to communicate language Receptive aphasia Refers to the ability to understand language Apraxia An oral motor speech disorder when an individual cannot translate what they want to say into motor plans to initiate speech Dysarthria Muscle weakness that affects speech production It is also important to remember not to mistake communication issue for cognitive problems and vice versa Interfering Factors with Cognitive Function Medical stability Medical issues, such as metabolic, pulmonary, endocrine, and sleep dysfunction can compromise cognition Impairments of emotional & al control can result directly from: Damage sustained directly to the brain Difficulties adjusting to deficits Pre-existing psychological factors A combination of these factors Interfering Factors with Cognitive Function MODELS Depression is a common comorbid condition to brain injury Co-morbid conditions can impact treatment participation and interfere with cognitive rehabilitation, thereby impacting overall outcomes Aggression, irritability noncompliance, and emotional lability are commonly seen after frontal lobe damage It is important to consider all factors (physical, language and speech, neurologic, and emotional/al) when providing cognitive rehabilitation PRINCIPLES COGNITIVE REHABILITATION Rainbow Rehab Centers 7

8 Models of Cognitive Rehabilitation Compensatory Approach Assumes certain cognitive functions cannot be recovered due to damage Focuses on development of strategies to accommodate limitations. For example, external devices such as planners, checklists, smart phones A functional application is essential Restorative Approach Repeated exposure and repetition of stimulation through experience can change brain s circuitry and reorganization of the brain can occur Uses therapeutic exercises designed to reestablish or strengthen specific cognitive skills or processes Compensatory and restorative approaches are used together to maximize recovery of function after brain injury Principles of Cognitive Rehabilitation When addressing cognitive deficits it is important to view both cognitive skills and their remediation as hierarchical and inter-related Basic cognitive skills should be addressed before higher level cognitive skills When treating cognition, less complex treatments should supersede treatments of greater complexity A hierarchical approach should target attention, perception, categorization, abstract thinking, and memory to restore/reorganize impaired cognition Examples include Attention Process Training and the Categorization Program Approaches 1. Environmental Stimulus (Quiet to Distracting) 2. Task Complexity (Simple to Complex) 3. Cognitive Distance (Concrete to Abstract) Overall Principles Environmental Stimulus Approach This approach uses modification of the environment so that initially it is controlled and enclosed to decrease external stimuli As progress is made, stimuli (e.g., distraction) are gradually re-introduced Overall Principles Task Complexity Begins with single step, simple tasks, and progresses to more complex multi-step tasks as each simpler task is mastered Can be decreased or increased depending on the individual s accuracy and time on task Overall Principles Cognitive Distance This concept relates to the complexity of information available As proximity to the object decreases, available information decreases In this example as we get further away from the red apple, less and less information is available Efficacy for Cognitive Rehabilitation has developed primarily in the last years Cognitive Rehabilitation is a crucial component to brain injury rehab Extensive reviews of literature have occurred and clinical practice guidelines have been developed It is essential that interventions must generalize to the real world outside of the clinical setting apple The disciplines that provide this essential service vary across the U. S. Color Black & White Line Word Spoken Rainbow Rehab Centers 8

9 Learning Objectives Be able to distinguish between positive and negative reinforcement Be able to describe the principles of applied analysis and how they apply to this population Neuroal Complications Chapter 11 Be able to identify and define common neuroal complications of brain injury Be able to articulate the concept and purpose behind a functional analysis Be able to discuss common neuroal treatment interventions Be familiar with factors that influence the type and extent of al difficulties an individual may demonstrate after a brain injury Be able to explain crisis prevention & management strategies for individuals with a brain injury Gain an understanding of de-escalation techniques to consider when individuals with brain injury are demonstrating increased frustration and agitation Introduction Neuroal issues are often considered to be the most problematic consequence of brain injury by family members, employers, friends, and others s can impact support systems and opportunities resulting in loneliness and isolation. For some, the consequences are more severe and can result in incarceration, homelessness, psychiatric hospitalization, substance abuse, and victimization Certified Brain Injury Specialists can play a critical role in implementing and evaluating the effectiveness of interventions Common Neuroal Changes after Brain Injury Aggression Agitation/irritability, poor frustration tolerance Poor initiation/apathy Denial of deficits/poor selfawareness Disinhibition/inappropriate sexual Eating disturbances Emotional changes including flat/restricted emotions, lability, dysphoria, depression Impulsivity Poor judgment and reasoning Psychosis - delusions, euphoria, hallucinations Nighttime disturbances Anxiety Factors Influencing Site and severity of damage Intelligence and learning style Pre-injury characteristics of personality The current environment Coma-Emergent Agitation Treatment of individuals in this stage of recovery can incorporate both medication and allybased interventions Often the safest and most efficient technique for dealing with this type of agitation in a based manner is through environmental management The focus is on offering a quiet, organized, and structured environment with limited and carefully managed stimulation Many individuals experience a period of agitation upon emerging from coma Usually brief, lasting less than 10 days in duration Characterized by hyperactive movement without purpose, and responding to internal stimuli rather than external Impulsive, unpredictable and/or disinhibited In early stages of recovery, as some individuals emerge from May attempt to remove coma, may be bizarre, unpredictable, impulsive, and restraints or tubes disinhibited Uncooperative with During this time consequence (or caregivers learning) based programming is not indicated as learning new information is unlikely Combative This phase is generally short in duration when medication and environmental based management are provided Rainbow Rehab Centers 9

10 Intervention for Coma-Emergent Agitation Environmental Interventions & Demands Education & Research Reduce noise and other extraneous stimuli; if possible, locate room in a quiet low-key setting Limit visitors (fewer for shorter periods of time) Eliminate television and technology (smart phones, computers, etc.) Incorporate familiar objects Provide safety without restraint when possible (veiled beds; sturdy, wide-wheeled wheelchairs that are less likely to tip; soft lap belts; padded hands mitts; proactive tube removal and the use of abdominal binder over tubing) Consider closed circuit television as an unobtrusive way to monitor for safety Use the same staff repeatedly Repeat routines to increase familiarity Offer care routines in small doses and follow the patient s lead when possible Provide frequent orientation as tolerated Use redirection and avoid confrontation Allow as much movement as is safe, including pacing in a safe environment Physicians may consider medications when necessary Ensure all staff are educated about comaemergent agitation Identify staff who are willing and able to take the lead and conduct 1:1s with these individuals Provide education to family members about what is happening, how to be supportive, and when to take a break Carefully monitor individual responses to medications, specific approaches, changes in Neuroal Approach to Treatment The Stability Triangle The Stability Triangle provides a guiding philosophy for the development of a comprehensive treatment plan The triangle specifies three primary areas that must be addressed in order for overall stability to be established and maintained It is applied in an ongoing manner to organize and guide treatment team efforts at all phases of rehabilitation and recovery The basic structure itself emphasizes that each element is interdependent, yet without any one side, stability is ultimately or eventually compromised Promote Stable Establish Medical Stability Develop Stable Activity Plan The Stability Triangle The Stability Triangle Establish Medical Stability Promote Stable The following factors are important as they can influence how an individual interacts with their environment Pain Sleep disturbance Incontinence Drug or alcohol use Vestibular issues Seizure disorders Inadequate or inappropriate medication use It is difficult to establish stability when an individual s medical complications impact their ability to respond in a consistent manner This requires the team to assess and address problematic s Resistance or refusal Mood instability Threatening or demanding s Verbal and physical aggression Property destruction Elopement Self-injurious Substance use or misuse The definition of within this treatment philosophy also includes thinking, saying, and doing It takes into account cognitive-al issues such as memory impairment, communication, and limited self-awareness al stability must be achieved and maintained in order to move ahead in other areas of rehabilitation programming The Stability Triangle Develop Stable Activity Plan The team must look toward helping an individual to explore and develop a stable activity plan Limited opportunities for meaningful engagement in routine activities are natural enemies to stability The team must explore an individual s abilities, interests, and need for support associated with specific activities and settings, and work to minimize all related risks APPLIED BEHAVIOR ANALYSIS Rainbow Rehab Centers 10

11 Applied Analysis Applied Analysis In the field of analysis anything an individual does that can be measured is defined as is often defined too narrowly and the term is reserved exclusively for instances of yelling, hitting or spitting In other situations the term can be applied too broadly, such as when persons who exhibit problematic s are identified as al May be addressed by: Analyst Psychologist Special Educators The goal of applied analysis is to discover variables that reliably influence to predict or promote change There are three variables that must be considered The Environment The Target The Individual The Individual Cognitive and physical impact of brain injury, stages of recovery and other factors such as pain or physical impairment greatly influence how the individual can interact with the environment The Environment Environmental factors include what has occurred and/or is currently occurring around the individual, both before and after the of interest is displayed This can include: Light Noise Temperature Smell Who is in the room Activities occurring The Target Program Elements Assess Define Target Collect Data Change Must be defined in objective and measurable terms so that it can be examined in a consistent and systematic manner Understanding the function of a means to understand the purpose that the serves for the individual in a particular situation Functional Analysis Operational Definition Determine Data to Collect Proactive or Consequence Based Approaches Rainbow Rehab Centers 11

12 Program Elements Assess Program Elements Define Target Assessment Methods There are indirect (interview of family, checklists by others) and direct methods for al assessment Direct methods are more reliable Functional assessments use direct methods Functional Assessment The goal is to understand the function the serves for the individual in a situation Identifying the function of a particular within a specific situation of interest is essential to the development and implementation of an effective change procedure A good assessment should include a list of s that will be targeted for decrease and increase In order to implement a change procedure, it is critical to identify the that is targeted for change In order to appropriately measure a, it must be operationally defined The must be: Observable Measureable Specific enough such that multiple observers would agree on what would count as an occurrence Topography and intensity are two dimensions of a that will be important to take into account when creating an operational definition Topography is what the looks like physically Intensity is a description or measure of force Program Elements Collect Data Program Elements Change Collect Data Frequency Count how many times a specific occurs. Frequency counts are often used for s which have a clear start and end (e.g., number of times someone rings a call bell, strikes another person, or attends a group). Rate Count per unit of time. Frequency alone can be misleading. For example, the statement John spit on staff twice does not tell us enough information: was it twice within the last hour or twice within the last four years? Measures of rate can help bring perspective to frequency counts. Duration Latency Percent Correct How long the lasts from start to end. The amount of time between the stimulus and the response. The number of correct responses out of the total possible number of responses. Sometimes s can be hard to count, such as when the does not have a specific start and end (e.g., yelling). In these cases, duration may be a more accurate measure. Duration may also be used when it is the specific element of interest (e.g., prolonged hand washing). Latency becomes important when the time between stimulus and response is a measure of interest: e.g., the time between delivery of a verbal cue from the PT to lift the left leg and when the individual s heel leaves the ground. This measure becomes important when teaching new skills. Examples can include the number of times that a person with brain injury correctly completes a sequencing task out of the number of times that the task is presented. Four Term Contingency Establishing Operation: Any variable that temporarily alters the effectiveness of some stimulus or event as a reinforcer Discriminative Stimulus: An event or stimulus that precedes a response and sets the occasion for the to occur Response/: Anything that can be done and measured Consequence: Any event that changes the probability of the response in the future two main types of consequences reinforcement and punishment is considered within a larger environment, with attention given to what occurs prior to the It is critical to understand the relationships between and individual, the and their environment Program Elements Four Term Contingency Examples Example 1 Example 2 Establishing Operation: Mary was not given her 9am pain medication which alleviates significant orthopedic pain Discriminative Stimulus: At 9:45 she is told that she has a physical therapy session Response/: She has an outburst, throws her walker and yells at staff Consequence: Staff remove her from the center, and she misses her physical therapy session Change Collect Data Establishing Operation: Mary was given her 9am pain medication which alleviates significant orthopedic pain Discriminative Stimulus: At 9:45 she is told that she has a physical therapy session Response/: She attends her physical therapy session Consequence: She had a very good session and was praised highly throughout Program Elements Proactive approaches to change Establishing operations and antecedents precede the They contribute to or influence the occurrences of the Consequences follow the They alter the likelihood of the occurring in the future Change With proactive approaches interventions are set up to reduce the likelihood of the occurring This is done by addressing the establishing operations and antecedents In the example in the previous slide, ensuring Mary had her pain medications was a proactive approach to decrease the likelihood of the target (outburst in the lobby) Rainbow Rehab Centers 12

13 Program Elements Change Consequence Based Intervention Another approach to change is a consequence based intervention Punishment: refers to any process that decreases the likelihood that a particular response will occur again in the future This involves implementing a systematic intervention where a target is followed by a specific type of consequence The type of consequence applied depends on whether the consequence is targeted for increase or decrease Negative Punishment There is the removal of a stimulus This decreases the likelihood that the response will occur again Positive Punishment There is the addition of a stimulus This decreases the likelihood that the response will occur again Consequence Based Intervention Reinforcement: any process that increases the likelihood that a particular response will occur again in the future A stimulus is added the likelihood of the increases A stimulus is removed the likelihood of the increases A student earns an A in algebra, Stimulus parent gives $20, Outcome and student is more likely to get A in future class A child puts toys away, Stimulus to avoid being nagged by parents, Outcome and the child is more likely to put toys away next time she plays Negative Reinforcement There is the removal of a stimulus This increases the likelihood that the response will occur again Positive Punishment There is the addition of a stimulus This increases the likelihood that the response will occur again A stimulus is added the likelihood of the decreases A stimulus is removed the likelihood of the decreases A driver speeds, Stimulus officer gives $200 ticket, Outcome and driver is less likely to speed Siblings fight over a toy, Stimulus parent takes away toy, Outcome and siblings are less likely to fight over toy Schedules of Reinforcement Extinction A particular response never produces a reinforcer The disappearance of a previously learned when the is no longer reinforced almost always increases before it goes away Intermittent Reinforcement A particular response sometimes produces a reinforcer Continuous Reinforcement A particular response always produces a reinforcer (1:1) Continuous Reinforcement Produces less variability in topography of Utilized to promote acquisition of is highly sensitive to extinction Think piece work and soda machines Rainbow Rehab Centers 13

14 Intermittent Reinforcement Task Analysis Produces greater variability in topography of Utilized to promote generalization and maintenance of is highly resistant to extinction Think hourly pay and slot machines A task analysis is a list of very specific steps involved in completing a task This can be used to break down larger tasks into smaller component steps Prompting & Cueing VISUAL AUDIBLE Shaping A technique in which successively closer approximations to the target response are reinforced until the target response occurs A process by which an individual is supported to display a correct response TACTILE ENVIRONMENTAL Goal: Train Butch to roll over when you say Roll-over Step 1: Say Roll-over ; Reward when he stands Step 2: Say Roll-over ; Reward only when he sits Step 3: Say Roll-over ; Reward only when he lays down Step 4: Say Roll-over ; Reward only when he starts to roll Step 5: Say Roll-over ; Reward only when he rolls over Stand Sit Lay Down Roll Roll Over Fading Fading is the process by which one learns to produce the same response under gradually changing conditions, in a manner implied by the same name of the procedure Fading involves providing gradually less support either from the environment or from another individual to display the target Teaching a child to read the word Apple First pair the word Apple with the red apple picture When the child can correctly name Apple, then prompt with the black & white apple Apple When the child can correctly name Apple then prompt with the outlined apple When the child can correctly name Apple fade out the apple picture altogether and leave just the word. Generalization When an organism responds similarly to different/ un-trained stimuli or situations Rainbow Rehab Centers 14

15 Discrimination: When an organism responds differently to similar stimuli Other Communication Considerations Personal space Body posture and motion Facial expression and gaze Tone, volume, and cadence of speech Crisis Intervention When De-escalation Techniques Fail Expectations All staff should be trained in de-escalation skills and crisis intervention This should include guidelines for effective and supportive non-verbal and para-verbal De-escalation Techniques Active Listening Orientation Redirection Setting Limits Withdrawing Attention Contracting CBIS staff are sometimes required to take physical action to keep individuals with brain injuries and themselves safe A situation is considered a crisis when immediate risk is posed to the individual or other persons There are many legal and ethical considerations that must be accounted for when individuals and facilities decide to employ physical intervention techniques including restraint and seclusion Restraint & Seclusion Restraint & Seclusion They are interventions of last resort CBIS Considerations Remain objective and neutral in the face of problem s Avoid labeling individuals and their s Used when less restricted measures are exhausted Only when individual or others are in imminent danger Highly regulated Poses risks to individuals and staff Those implementing these techniques can be held personally accountable Always followed by medical attention for the individual, debriefing, and formal documentation s are related to Brain Injury factors (e.g. communication difficulties, lack of awareness, pain, etc.); they are not personal Daily activities of the CBIS involve: Observation & reporting Data collection Implementation of strategies and approaches Rainbow Rehab Centers 15

16 Learning Objectives Be able to summarize the contributions of Gall and Spurzheim in the development of modern neuropsychology Be able to discuss the concept of the functional systems model Be able to explain the difference between clinical and experimental neuropsychology Be familiar with the assessment process Neuropsychology Chapter 22 Be able to distinguish between restorative and compensatory approaches to cognitive treatment Be able to identify the four components of cognitive rehabilitation General History There is a long history of interest in brain relationships Trepanning: dates back to the Mesolithic period, similar to the modern practices of creating burr holes in the skull to relieve intracranial pressure Phrenology: Developed by Gall and Spurzheim; It was believed that different parts of the human cortex controlled different mental functions Early localization: Gall established the presence of various brain organs that serve as the local centers for various aspects of mental functions Phrenology was debunked as a science but it did provide important precursors of modern understanding of brain- relationships, namely localization of brain functions General History Alexander Luria proposed that localization of functions cannot solely explain He proposed the Functional Systems Model s consist of a number of simple mental operations that are localized to a specific part of the brain Thoughts, movements, sensations, heartbeats (i.e., )produced by the collaboration of the local brain sites that control the mental operations composing it Brain areas needed for a can be located close together or can dispersed throughout the brain Success of a depends on intact functioning of specific brain localized areas, and intact connections between those areas Disruption to any component of the functional system can lead to a breakdown of the entire al function The frontal lobe and its extensive connections are a prime example What is Neuropsychology? Neuropsychology is the science of brain- relationships Field of Study Focus Functional Systems Brain activity is the result of a system of activity Local areas are specialized for processing These area processes work together Psychology Neurology Neuropsychology Focuses on understanding without always considering the role of the nervous system Focuses on the functioning of the nervous system without always considering its effect on Focuses on how the two interact Assemblies of smaller units of processing make up larger units and networks In this way multiple inputs can be processed into a set of complex s Rainbow Rehab Centers 16

17 Clinical vs. Experimental Neuropsychology: Differences in approaches Neuropsychology Assessment Purpose Results of a neuropsychological evaluation provide a detailed description of the individual s abilities, strengths, and weaknesses in various areas of functioning Determine the nature and extent of cognitive deficits, including patterns of functioning in developmental and many psychiatric disorders Determine the presence of a neurologically based disorder Understand how specific cognitive deficits may contribute to problems in daily life Establish a baseline and document skills at a specific point in time, to compare to future assessments Determine the nature and degree of change in cognitive performance on re assessment Assist in treatment planning Determine the appropriateness of a surgical intervention Make recommendations for modifications or accommodations in the community Scope of a Neuropsychology Assessment Comprehensive assessments assess multiple cognitive domains, and the scope of evaluations can vary depending on need Premorbid functioning used to compare a person s current and expected level of performance Attention and concentration Sensory perception and psychomotor functioning Information processing speed Language and communication skills Visuospatial and constructional skills Learning and memory Intelligence (intellectual achievement) Figure 5: A critical aspect of neuropsychological assessment involves the use of normative data for comparing a patient s Executive functions test scores to an empirical standard Additional factors that can affect cognitive functioning, including mood, anxiety, personality,, medications, effort and motivation Assessment Instruments The assessment involves the administration of specialized tests that measure al performance of brain functions (e.g., attention, memory, etc.) They are completed in a standardized fashion, involving two key principles: Manualized Procedures There are standard protocols for the administration of each assessment This increases the chance that a score is representative of the individual s ability, and not the impact of other factors Normative Data When assessments are complete, the individual s scores are referenced against normative data Norms represent a range of typical performance in a population of healthy individuals The Assessment Process The Assessment Process Assessment begins with a Record Review Sometimes this involves a great deal of useful information: Past medical record Results of prior assessments Imaging Specific details regarding al and functional impairments The Clinical Interview typically covers Referral information Presenting complaints Developmental history Educational and vocational background Psychosocial history Medical history Family history Substance use and current medications Current level of functioning Rainbow Rehab Centers 17

18 The Assessment Process The Assessment Process Standardized Testing has two general approaches - fixed battery and flexible battery The fixed battery approach involves an exhaustive battery of standardized, conormed tests that thoroughly cover every functional domain The flexible battery is a patient-tailored hypothesis testing approach, and involves selection of assessment instruments based on careful consideration of the referral question and impressions from the initial interview Background information gathered from the referral source, medical records, and interview al observations (appearance, speech, gait, mood, affect, thought process) Factors relevant to test validity (awareness, effort, motivation, comprehension of test instructions, mood disturbance, psychosis) List of administered tests Description and interpretation of the patient s performance on tasks within each cognitive domain assessed Summary, including the patient s cognitive strengths and weaknesses, clinical impression, potential neuroanatomical involvement, functional implications, and diagnostic considerations Recommendations for treatment and further assessment Cognitive Rehabilitation Cognitive Education focuses on developing a patient s awareness of cognitive and functional deficits through education on weaknesses and strengths Cognitive Training focuses on resolving the cognitive and functional deficits through the application of restorative approaches Strategy Training focuses on the application of compensatory approaches to address residual deficits not amenable to natural recovery and cognitive training Functional Training focuses on real world improvements in daily functioning E ND 107 T HE Rainbow Rehab Centers 18