Guidelines | Attention | Compensatory Strategies

General Guidelines for Neurocognitive Therapy™ with Individual’s with Acquired Cognitive Impairment:

The strategies utilized for neurocognitive therapy are guided by the type and degree of injury and variables of neurological and neurobehavioral recovery. These include: age, time since injury, gender, premorbid IQ, the brain’s neuro-plasticity, premorbid medical conditions, prior history of brain trauma or illness and potential for synaptic reorganization and regeneration. The following principles are offered by Sohlberg and Mateer (2001).

• The necessity of early intervention is well documented in the literature (e.g. Lezak, 1979; Cope and Hall, 1982). Early intervention assures maximum recovery potential although intervention done too early can be therapeutically contraindicated.
• The level of impairment and treatment progression is evaluated from multiple sources within the interdisciplinary model. Treatment is based and updated from both the results of testing, collateral data and current functioning.
• Cognitive rehabilitation is guided by set goals established from the individual’s strengths and challenges. In general goals focus on independence, empowerment, education, and autonomy. Specifically, goals may include elements of the improvement of cognitive skills, compensatory strategies, adjustment, improvement of awareness/insight, community, career or school reentry, family role changes and addressing negative mood or behaviors.
• Independence is solidified through a focus on generalization and maintenance of skills. When possible the patient will be assisted in utilizing learned skills within the patient’s home, work or school environment.
• Both treatment and evaluative techniques are guided by new technologies and theories with a consistent measure of the efficacy of treatment and overall outcome. The treatment techniques are empirically based with ongoing internal research to measure the program’s efficacy and to pilot new methods and procedures.
• Cognitive rehabilitation emphasizes collaboration with the patient, family and work and school. Active participation is essential throughout the process.
• Treatment is guided by informed medical and neurological evaluation and is adjusted for the individual patient’s needs within a cognitive, physical, social and emotional perspective. Individual components of the person’s beliefs, values, culture, personality and behaviors are incorporated into the therapy regimen.
• Cognitive functions that respond to treatment should be prioritized and intervention done accordingly. Compensatory strategies should be provided for those skills where treatment is contraindicated. For example, overt self-talk can be utilized for self monitoring while a retention memory deficit will require compensation.
• Accuracy should supercede speed. Self-esteem and independence are always an underlying goal. Maximize the likelihood of correct responses rather than correcting incorrect answers.
• Cognitive therapy is goal oriented but the development of positive experience post-injury for the patient to draw upon should not be underestimated. When behavioral modification is the goal, consequences are the focus. Behavioral chaining and shaping should be used to modify behaviors. Partial successes can be linked to form more complex results. Cognitive and behavioral growth post injury is achieved through the patient’s internalization of small successes resulting in the reconstruction of confidence, and internal locus of control and strengthened ego identity.
• Effective generalization strategies will be the key to offering the patient the skills to function in a variety of settings and to establish and maintain independence. New skills are not merely taught but processed and individualized.
• Cognitive functions are hierarchical in nature. Deficits in complex attention may for example reveal themselves in learning and memory deficits. It is therefore not only important to identify each deficit but also to delineate the etiology of the deficit. Brain damage often leads to difficulty with memory. Once the nature of the deficit is understood (e.g. retention vs. recall) strategies can be taught

Attention Training Interventions:
Examples of specific interventions include: (Sohlberg & Mateer, 2001): 

• Sustained attention (Concentration)
• Mental math activities such as the PASAT
• Paragraph-listening comprehension exercises (e.g. counting the number of target words and then discussing the content of the paragraph)
• Letter and number sequencing exercises such as auditory digit span or letter number sequencing
• Exercises that require listening for target words or watching for target numbers and performing a response when identified

Alternating attention (Attention Switching):

• Switching between two activities after a predetermined auditory or visual stimulus is received (e.g. adding a series of verbally presented number and then moving to subtracting the numbers once a light is flashed)
• Exercises that require counting a target word in a verbally presented passage and then switching to counting a second word after a given stimulus
• Group activities where the patient’s are given a timed task within a contest format and asked to respond in differing manners depending upon the circumstances (e.g. raising hands if the task involves numbers and clapping if the task involves letters).

Selective attention:

• Sustained attention tasks with built in distracters
• Watching for predetermined themes in a television show that each group members agrees to watch (focus on the clothes worn by the characters or the foods eaten)
• Listening to the content of one passage as two are read simultaneously
• Tasks designed to compare distracters from the same domain functioning (e.g. auditory) with different domains (e.g. auditory and visual)

Divided attention:

• Completing an auditory sustained attention task while simultaneously performing a reaction time task (listening to a story while playing “slapjack”).
• Listening to a presentation from a patient while simultaneously scanning for a target word or phrase
• Completing a timed activity (e.g. number searches) while simultaneously engaging in a sustained attention activity such as listening to an audio tape
• Utilizing any of the alternating attention tasks with the directions modified to track both activities simultaneously

Compensatory Strategies:

Although the primary goal of Neurocognitive therapy is to restore the patient’s capacity to process information “on-line”, there will be strategies offered to compensate for this loss of functioning or in preparation for reserving cognitive energy combat fatigue. Attention is conceptualized as the conscious energy required to internalize external data. Attention requires energy and compensatory strategies serve to conserve cognitive energy. These strategies are useful when a specific task must be learned. Along with compensatory strategies, the patient must be taught to pace themselves and to recognize the early symptoms of fatigue. Strategies must be built in to rejuvenate cognitive energy by pacing via time intervals or by task completion. More challenging tasks can be addressed in the morning when the patient is rested and sleep patterns can be adjusted to alleviate fatigue throughout the day.

Compensatory strategies are equally effective in assisting the patient in their integration back to home, work or school and serve as an excellent supplement to attention training. When implementing compensatory strategies, there are several considerations that will enhance the success and ensure the efficacy of the approach. First of all, the patient’s expectations of the outcome of the strategy must be realistic and attainable. The success of the strategy is dependent upon a comprehensive understanding of the circumstances in which the strategy will be implemented. This will involve an active collaboration with the patient in selecting and implementing strategies. This working alliance will ensure the success of the techniques employed. Along with the development and implementation of the strategy there will need to be a means by which to measure its success or failure. Compensatory strategies can be divided into the categories of:

• attention prosthetics
• conscious monitoring
• psychosocial support