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Neurocognitive Issues Section 4

THE ESSENTIAL BRAIN INJURY

GUIDE

ContributorsLisa A. Kreber, PhD, CBISDrew A. Nagele, PsyDChristina Peters, MSc Ed, BCBA, CBISChris M. Schaub, MS EDMJ Schmidt, MA, CBIS

Cognitive Complications Chapter 10

Learning Objectives

Be familiar with the 5 subtypes of

attention

Gain an understanding

of the concepts involved in cognitive

rehabilitation

Be able to distinguish between the 4 types

of memory

Be able to describe the types of deficits in

attention frequentlyobserved in persons

who have sustained a brain injury

Be able to articulate the type of damage

sustained by TBI that results in delays in

information processing

Be able to explain factors that interfere

with cognitiverehabilitation

Over 5 million Americans experience disabilities due to brain injury

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 ..

.. and other areas of cognition that can impact a person’s ability to successfully participate in activities of daily living

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Cognitive Impairments can Impact:

Remediation can improve a person’s ability to engage in

social interactions, recreation, and productive activities like

work and school

• Level of independence• Educational or vocational engagement • Social interaction• Family interaction• Life satisfaction

Alertness Association Attention Attention Span AwarenessCategorizing

Comprehension Decision-making Insight Learning Maintenance of

sequential goal-directed behavior with self-correction

Maintenance of temporal order of stimuli

MemoryOrganizing Planning Problem-solving Reasoning

Retention Selective Attention Stimuli Recognition Stimuli Discrimination Synthesis of

Information Thinking

Cognitive Skills and Processes Identified by ASHA and ACRM.

What is Cognition?It is a complex collection of conscious mental activities, such as attention, perception, comprehension, remembering, or using language

It is a process by which sensory input transformedreduced, elaborated,

is

recovered and used

Cognitive Skills and Processes

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

For example… damage to the attention network of the brain will affect attention and also memory functions

Retraining of fundamental cognitive processes can result in reorganization of higher level or more complex cognitive processes

Domains of Cognitive Functioning

Categorization

ATTENTION

Attention One of the most fundamental

cognitive skill sets Influences all other cognitive

skills Deficits in this area are

common after brain injury

FOCUSED

SUSTAINED

SELECTIVE

ALTERNATING

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

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Subtypes of Attention Descriptions Examples

FocusedAttention

Selecting one source of information (i.e., stimulus) while withholding responses to irrelevant stimuli

Responding to pain; Turning to see a loud sound behind you

SustainedAttention

Maintaining attention to complete a task accurately and efficiently over a period of time

Reading a book; Watching a TV show; Listening to a presentation

Selective Attention

Maintaining attention in the presence of distractions

Focusing on the presenter at a conference while ignoring others talking outside; Studying while music is playing

Alternating Attention

Shifting between tasks that demand different behavioral or cognitive skills

Reading a recipe and stirring a pot; Filing and answering the phone

Divided Attention

Requires the ability to respondsimultaneously to multiple task demands while maintaining speed and accuracy

Driving and talking on the phone; Cooking multiple courses at the same time

Deficits of Attention

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

Attention Process Training Program (APT)

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

Categorization

Categorization skills are important in: Speed of processing Problem solving Other higher order cognitive

processes (e.g., decision-making)

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

Individuals with brain injuries tend to base decisionscategory membership according to a

single attribute and have difficulty responding to more complex and multidimensional stimuli

about

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CATEGORIZATIONRemediation

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

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MEMORY

Memory

Memory impairments can arise from difficulty in the encoding, storage or retrieval of information

Memory

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

Sensory Memory

Short Term Memory

Working Memory

Long Term Memory

Taste

Vision

Touch

Hearing

Smell

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

Memory Processes

Rehearsal

Retrieval

Holds information from the senses for a few seconds immediately after the item is perceived

There are five sensory memory senses

Sensory Memory

Short Term & Working Memory

Enables recall of information that lasts a few minutes to hours

Example: the color of a car that just passed you

Is a central cognitive process responsible for the temporary storage and active processing of information

Example: calculating change in your head

Short Term Memory Working Memory

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

It is divided into explicit and

implicit memory

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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

Long Term Memory

Implicit Memory

Implicit memory comes in the form of

procedural and cognitive skill 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

Long Term Memory

Explicit Memory

PROCESSING SPEED

Processing Speed

When impaired, the rate at which new information can be attended to and later recalled is also impaired

Cognitive reaction time, or the time it takes a person to gather the information presented, process it, and respond

Must be targeted across all cognitive skills

EXECUTIVE FUNCTIONS

Executive Functions

Abstract thought

Analyzing all aspects of a situation

Considering all potential solutions to a problem

Executing those solutions

Maintaining cognitive flexibility if one solution does not work

Self-monitoring

Injury can result in problems with:

Complex cognitive

reasoning, processes that involve

planning,judgment, initiation,and abstract thinking

Executive functions are

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Hold info in mind to complete task; Update & manipulate info

Age appropriate insight of strengths & weaknesses

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

Independently assess behavior; Respond to and make changes as needed

Impulse control; Manage distractions; Delay responses

Move freely from one activity to another; Consider more than one solution when problem solving

Create useful strategy for functional use

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

MetacognitionMetacognition 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

Executive functions have been conceptualized as cognitive directors since they assist in the interaction between other cognitive processes, such as memory, attention and perception

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)

Metacognitive functions can similarly be viewed as awareness directorssince they oversee the thinking processes, allowing knowledge of thinking about thinking

Metacognition

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

Used to enhance an individual’s ability to internalize awareness and control over behaviors

The primary goal of metacognitive strategy training is to enhance a person’s ability to internalize awareness and control over their behavior

Anosognosia Metacognitive Strategy Training

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COGNITIVE FUNCTION

Cognitive function is widely distributed across many regions

and structures of the brain

Frontal Systems

Parietal Systems

Temporal Systems

Occipital Systems

Limbic Systems

Temporal Lobe Memory Face recognition Selective attention Locating objects

Object categorization Receptive language Emotional responses Language comprehension

Emotional control Behavioral control Verbal expression Problem Solving Decision Making Social control Motivation Attention

Frontal Lobe

Visual stimuli processing

Occipital Lobe

Tactile performance Spatial orientation Academic skills Object naming Visual attention Eye-hand coordination

Parietal Lobe

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.

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

Common Factors that Interfere with Cognitive Function Following a Brain Injury:

It is also important to remember not to

mistake communication issue for cognitive

problems and vice versa

Communicative FunctionsExpressive 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

Interfering Factors with Cognitive Function

Medical stability Medical issues, such as metabolic, pulmonary, endocrine,

and sleep dysfunction can compromise cognition

Impairments of emotional & behavioral 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

Depression is a common co-morbid condition to brain injury

Aggression, irritability non-compliance, and emotional lability are commonly seen after frontal lobe damage

It is important to consider all factors (physical, language and speech, neurologic, and emotional/behavioral) when providing cognitive rehabilitation

Co-morbid conditions can impact treatment participation and

interfere with cognitive rehabilitation, thereby impacting

overall outcomes

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COGNITIVE REHABILITATION

MODELS

PRINCIPLES

Models of Cognitive Rehabilitation

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

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 Approach Restorative Approach

Compensatory and restorative approaches are used together to maximize recovery of function after brain injury

Principles of Cognitive Rehabilitation

1. Environmental Stimulus

2. Task Complexity

3. Cognitive Distance

(Quiet to Distracting)

(Simple to Complex)

(Concrete to Abstract)

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

Overall PrinciplesEnvironmental 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 PrinciplesCognitive 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

SpokenColor Black & White Line Word

apple

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Efficacy for Cognitive Rehabilitation has developed primarily in the last 10-15 years

Cognitive Rehabilitation is a crucial component to brain injury rehabilitation

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

The disciplines that provide this essential service vary across the U. S.

Neurobehavioral Complications Chapter 11

Learning Objectives

Be able to distinguish between positive and

negative reinforcement

Be able to describe the principles of applied

behavior analysis and how they apply to this

population

Be able to articulate the concept and

purpose behind a functional

analysis

Be able to explain crisis prevention & behavior

management strategies for individuals with a

brain injury

Be familiar with factors that influence thetype and extent of

behavioral difficultiesan individual may

demonstrate after abrain injury

Be able to identify and define common neurobehavioral

complications of braininjury

Gain an understanding of de-escalation techniques

to consider when individuals with brain

injury are demonstrating increased frustration and

agitation

Be able to discuss common

neurobehavioral treatment interventions

Introduction

Neurobehavioral issues are often considered to be the most problematic consequence of brain injury by family members, employers, friends, and others

Behaviors 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 Neurobehavioral Changes after Brain Injury Aggression Agitation/irritability, poor

frustration tolerance Poor initiation/apathy Denial of deficits/poor self-

awareness Disinhibition/inappropriate

sexual behavior 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

Behavior

Site and severity of damage

Pre-injury characteristics of

personality

Intelligence and learning style

The current environment

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Coma-Emergent Agitation

Treatment of individuals in this stage of recovery can incorporate both medication and behaviorally‐based interventions

Often the safest and most efficient technique for dealing with this type of agitation in a behavior‐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

In early stages of recovery, as some individuals emerge from coma, behavior may be bizarre, unpredictable, impulsive, and disinhibited

During this time consequence (or learning) based programming is not indicated as learning new information is unlikely

This phase is generally short in duration when medication and environmental based management are provided

Impulsive, unpredictable and/or disinhibited behavior

May attempt to remove restraints or tubes

Uncooperative with caregivers

Combative

Environmental Interventions & Demands Education & Research

Reduce noise and other extraneous stimuli; if possible, locate room in a quiet low-key setting

Use the same staff repeatedly Ensure all staff are educated about coma-emergent agitation

Limit visitors (fewer for shorter periods of time) Repeat routines to increase familiarity

Identify staff who are willing and able to take the lead and conduct 1:1s with these individuals

Eliminate television and technology (smart phones, computers, etc.)

Offer care routines in small doses and follow the patient’s lead when possible

Provide education to family members about what is happening, how to be supportive, and when to take a break

Incorporate familiar objects Provide frequent orientation as tolerated

Carefully monitor individual responses to medications, specific approaches, changes in behavior

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)

Use redirection and avoid confrontation

Consider closed circuit television as an unobtrusive way to monitor for safety

Allow as much movement as is safe, including pacing in a safe environment

Physicians may consider medications when necessary

Intervention for Coma-Emergent Agitation

Neurobehavioral Approach to Treatment The Stability TriangleThe Stability Triangle provides a guiding philosophy for the development of a comprehensive treatment plan

Establish Medical Stability

Promote Stable Behavior

Develop Stable Activity 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

The Stability Triangle

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 behavior stability when an individual’s

medical complications impact their ability to respond in a

consistent manner

Establish Medical Stability

The Stability Triangle

This requires the team to assess and address problematic behaviors Resistance or refusal Mood instability Threatening or demanding behaviors Verbal and physical aggression Property destruction Elopement Self-injurious behavior Substance use or misuse

The definition of behavior within this treatment philosophy also includes thinking, saying, and doing

It takes into account cognitive-behavioral issues such as memory impairment, communication, and limited self-awareness

Behavioral stability must be achieved and maintained in order to move ahead in other areas of rehabilitation programming

Promote Stable Behavior

The Stability Triangle

The team must look toward helping an individual to explore and develop a stable activity plan

Develop 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

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APPLIED BEHAVIOR ANALYSIS

Applied Behavior Analysis

May be addressed by: Behavior Analyst Psychologist Special Educators

In the field of behavior analysis anything an individual does that can be measured is defined as behavior

Behavior is often defined too narrowly and the term “behavior” 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 behaviors are identified as “behavioral”

Applied Behavior Analysis

The goal of applied behavior analysis is to discover variables that reliably influence behavior to predict behavior or promote behavior change

There are three variables that must be considered

The Individual

The Target Behavior

The Environment

The IndividualCognitive 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 EnvironmentEnvironmental factors include what has occurred and/or is currently occurring around the individual, both before and after the behavior of interest is displayed

This can include: Light Noise Temperature Smell Who is in the room Activities occurring

The Target Behavior

Must be defined in objective and measurableterms so that it can be examined in a consistent and systematic manner

Understanding the function of a behavior means to understand the purpose that the behavior serves for the individual in a particular situation

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Behavior Program Elements

AssessBehavior

Define Target Behavior

CollectData

Functional Analysis

Change Behavior

Operational Definition

Determine Data to Collect

Proactive or Consequence Based

Approaches

Behavior Program Elements

There are indirect (interview of family, checklists by others) and directmethods for behavioral assessment

Direct methods are more reliable Functional assessments use direct

methods

The goal is to understand the function the behavior serves for the individual in a situation

Identifying the function of a particular behavior within a specific situation of interest is essential to the development and implementation of an effective behavior change procedure

A good assessment should include a list of behaviors that will be targeted for decrease and increase

Assessment Methods Functional Assessment

AssessBehavior

Behavior Program Elements In order to implement a behavior

change procedure, it is critical to identify the behavior that is targeted for change

In order to appropriately measure a behavior, it must be operationally defined

The behavior must be: Observable Measureable Specific enough such that multiple

observers would agree on what would count as an occurrence

Define Target Behavior

Topography and intensity are two dimensions of a behavior that will be important to take into account when creating an operational definition Topography is what the

behavior looks like physically Intensity is a description or

measure of force

Behavior Program Elements CollectData

Frequency Count how many times a specific behavior occurs.

Frequency counts are often used for behaviors 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 How long the behavior lasts from start to end.

Sometimes behaviors can be hard to count, such as when the behavior 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 The amount of time between the stimulus and the response.

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.

Percent Correct

The number of correct responses out of the total possible number of responses.

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.

Behavior Program ElementsFour 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 behavior to occur

Response/Behavior: 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

Behavior is considered within a larger environment, with attention given to what occurs prior to the behavior

It is critical to understand the relationships between an individual, the behavior, and their environment

Change Behavior

CollectData Behavior Program Elements

Four Term Contingency Examples

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/Behavior: 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 Behavior

CollectData

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/Behavior: She attends her physical therapy session

Consequence: She had a very good session and was praised highly throughout

Example 1 Example 2

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Behavior Program Elements With proactive approaches

interventions are set up to reduce the likelihood of the behavior 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 behavior (outburst in the lobby)

Proactive approaches to behavior change

Establishing operations and antecedents precede the behavior

They contribute to or influence the occurrences of the behavior

Consequences follow the behavior

They alter the likelihood of the behavior occurring in the future

Change Behavior

Another approach to behavior change is a consequence based intervention

This involves implementing a systematic intervention where a target behavior is followed by a specific type of consequence

The type of consequence applied depends on whether the consequence is targeted for increase or decrease

Behavior Program Elements Change Behavior

Consequence Based Intervention Punishment: refers to any process that decreases the

likelihood that a particular response will occur again in the future

Positive Punishment There is the addition of

a stimulus This decreases the

likelihood that the response will occur again

Negative Punishment There is the removal 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

Negative Reinforcement There is the removal of a

stimulus This increases the

likelihood that the response will occur again

Positive Reinforcement 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

behavior increases

A stimulus is removed – the likelihood of the

behavior increases

A stimulus is added –the likelihood of the behavior decreases

A stimulus is removed – the likelihood of the

behavior decreases

BehaviorA driver speeds, Stimulusofficer gives $200 ticket, Outcomeand driver is less likely to speed

BehaviorSiblings fight over a toy, Stimulusparent takes away toy, Outcomeand siblings are less likely to fight over toy

BehaviorA child puts toys away,Stimulusto avoid being nagged by parents, Outcomeand the child is more likely to put toys away next time she plays

BehaviorA student earns an A in algebra,Stimulusparent gives $20,Outcomeand student is more likely to get A in future class

Schedules of Reinforcement Extinction A particular response never produces a reinforcer The disappearance of a previously learned

behavior when the behavior is no longer reinforced Behavior 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)

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Continuous Reinforcement

Produces less variability in topography of behavior

Utilized to promote acquisition of behavior

Behavior is highly sensitive to extinction

Think piece work and soda machines

Intermittent Reinforcement

Produces greater variability in topography of behavior

Utilized to promote generalization and maintenance of behavior

Behavior is highly resistant to extinction

Think hourly pay and slot machines

Task Analysis

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

TACTILE ENVIRONMENTALA process by which an individual is

supported to display a correct response

Shaping A technique in which successively closer approximations to the target response are reinforced until the target response occurs

Goal: Train Butch to roll over when you say “Roll-over”

Step 1: Say “Roll-over”; Reward when he stands

Stand Sit Lay Down Roll Roll Over

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

FadingFading 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 behavior

Apple

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

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.

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Generalization When an organism responds similarly to different/

un-trained stimuli or situations

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 InterventionExpectations

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 behavior

De-escalation Techniques

Active Listening

Orientation

Redirection

Setting Limits

Withdrawing Attention

Contracting

When De-escalation Techniques Fail…

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

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

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CBIS Considerations

Remain objective and neutral in the face of problem behaviors

Avoid labeling individuals and their behaviors

Behaviors 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 & reportingData collectionImplementation of strategies and approaches

NeuropsychologyChapter 22

Be able to distinguish between restorative and

compensatory approaches to cognitive

treatment

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

Be able to identify the four components of

cognitive rehabilitation

General History

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

Phrenology was debunked as a science but it did provide important precursors of modern understanding of brain-behavior relationships, namely localization of brain functions

There is a long history of interest in brain behavior relationships

Early localization: Gall established the presence of various brain organs that serve as the local centers for various aspects of mental functions

General History

He proposed the Functional Systems Model

Behaviors consist of a number of simple mental operations that are localized to a specific part of the brain

Thoughts, movements, sensations, heartbeats (i.e., behavior )produced by the collaboration of the local brain sites that control the mental operations composing it

Brain areas needed for a behavior can be located close together or can dispersed throughout the brain

Success of a behavior 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 behavioral function

The frontal lobe and its extensive connections are a prime example

Alexander Luria proposed that localization of functions cannot solely explain behavior

What is Neuropsychology?

Field of Study Focus

Psychology Focuses on understanding behavior without always considering the role of the nervous system

Neurology Focuses on the functioning of the nervous system without alwaysconsidering its effect on behavior

Neuropsychology Focuses on how the two interact

Neuropsychology is the science of brain-behavior relationships

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Functional Systems

Local areas are specialized for processing

These area processes work together

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 behaviors

Brain activity is the result of a system of activityClinical vs. Experimental Neuropsychology:

Differences in approaches

Neuropsychology Assessment Purpose

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

Results of a neuropsychological evaluation provide a detailed description of the individual’s abilities, strengths, and weaknesses in various areas of functioning

Figure 5: A critical aspect of neuropsychological assessment involves the use of normative data for comparing a patient’s

test scores to an empirical standard

Scope of a Neuropsychology Assessment

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)

Executive functions

Additional factors that can affect cognitive functioning, including mood, anxiety, personality, behavior, medications, effort and motivation

Comprehensive assessments assess multiple cognitive domains, and the scope of evaluations can vary depending on need

Assessment Instruments

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

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

Manualized Procedures Normative Data

The assessment involves the administration of specialized tests that measure behavioral performance of brain functions (e.g., attention, memory, etc.)

They are completed in a standardized fashion, involving two key principles:

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 behavioral and functional impairments

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The Assessment Process

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

The Assessment Process

Standardized Testing has two general approaches - fixed battery and flexible battery

The fixed battery approach involves an exhaustive battery of standardized, co-normed 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

The Assessment Process

Background information gathered from the referral source, medical records, and interview

Behavioral 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 approachesto address residual deficits not amenable to naturalrecovery and cognitive training

Functional Training focuses on real-worldimprovements in daily functioning

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