Diagnosis and Therapy Approaches for the Speech Language Pathologist

Cognitive Functions Domains of Cognitive Function 1.Attention 2.Memory Processes :short and long term 3.Verbal language 4.Categorization :Means of incorporating new info and organizing info in the brain 5.Abstract thought Constantinidou, Thomas, & Best (2004)

1.Attention Orienting Network Guides the sensory organs to relevant locations within the environment so that processing of information in those locations is enhanced Executive Network -Central executive” coordinates working memory, orienting network, and processes of the short term memory Alerting Network Ability to maintain arousal or alertness

Orienting Network Attentional orienting is closely tied to shifting the gaze of the eyes to expand the visual field in which the organism must respond Selective, focused, sustained, shared, shifted- With brain damage this basic skill is often affected and impedes learning In terms of survival in the “wild”, this impairment may be fatal.

Executive Network The Executive Network is responsible for assessing the situation, ensuring the most important features are amplified and selecting the most important responses. Prioritizing List situations where Executive Network is employed in daily life: Driving? Planning dinner Time schedules

Executive Network Flexibility Capacity to multitask Switch attention Organize sequences For Word Finding: one may alter response selection (if you can’t think of the word, you sometimes use another in the file that you can retrieve that is like it)

Alerting Network Ability to maintain arousal or alertness Ability to discriminate the presence of distracters (vigilance) One Cognitive therapy might include learning to recognize and control adverse environmental and personal conditions, training the person to become resistive to distractions

2.Memory Processes in the Executive Network Memory is organized with respect to time and contents Short term/working memory Long term memory explicit- semantic, experiential event Someone with damage to the Explicit portion of the Executive Network will be disoriented, not remember the space or the room where they always have therapy, and demonstrate nervous behavior implicit-skills and habits, perceptual, conditioning

3.Verbal Language Brain injury can result in a generalized cognitive disruptions that often affects complex linguistic abilities Traditional aphasic syndromes are not often associated with TBI Word finding / lexical retrieval – associated in TBI with slower speed of information processing along with retrieval difficulties

4. Categorization Assigning objects or events into groups Interrelated with other cognitive processes Object recognition Problem solving Decision making Sustained attention tasks that require sorting Learning and memory Categorization is critical to problem solving in order to consider solutions

Components of Categorization Recognition and Categorization of everyday objects involves two anatomically and functionally distinct pathways. Brain Injury may cause deficits in both identification and categorization because the two areas of the brain are not communicating.

5. Abstract thought Reasoning Decision making and Problem solving are the highest forms of cognition in what we think of as human intelligence Abstract thought emerges from the interaction of all the other processes Dementia, Degenerative disorders and TBI >reduction in abstract thinking

Memory processes table Attach at the end

TBI, CHI, CVA, Progressive Aphasia, Dementia, Developmental, Autism spectrum, CP, LD, may each be faced with challenges: Attention Organization and categorization difficulties Learning difficulties Memory deficits Information processing impairments Executive functioning deficits Reasoning, decision making, problem solving Psycho social- anxiety and depression Social-Communication difficulties Receptive and Expressive Language Patients we have known:? Adults * Children- different but may show cognitive deficits during development

Approaches to Diagnosis We obtain functional information in a good New Client / caregiver interview 1. Static -quantitative diagnostics : tests one point in time/normed Cognitive Linguistic Quick Test Cognitive Abilities Screening Test Functional Communication Profile Language -Cognitive-Communication WAIS III-Digit Backward and Symbol Subtest Boston Diagnostic Aphasia Exam-has subtests which test cognitive functions Stroop Color Word Test Note: on many of the test, especially the WAIS III, the premorbid intellect measures may affect the performance

Approaches to Diagnostics 2.Qualitative: observation of behaviors during tasks performance. Provides info on how task is performed 3.Dynamic assessment: not a single packet or procedure but a model and philosophy that : All people are capable of some degree of learning (stimulus/cueing hierarchies) Diagnostic therapy is dynamic assessment: the assessor actively intervenes with the goal of intentionally inducing changes *2 & 3: Viewed as an addition to the other approaches but not a substitute for existing procedures

Differential Diagnostics Differential Diagnosis of Aphasia, Cognitive disorders and progressive disorders, Dementias Conditions may co-occur [Think of your caseload and identify aspects of language vs. cognitive function. How does one effect the other?] The functions may be located in different areas of the brain If they do not interact well = cognitive disorders

Approaches to Therapy What do we know about how learning and behavior are indicators of what is going on neurologically? Restorative Compensatory Skill building Repetition Stimulus/Cueing Hierarchies How do our therapies help the client develop functional skills for life? Based on the assumption that some abilities may not be restored completely Develop functional strategies

Brain reorganization and sprouting following injury Phagocytes clean Out damaged neurons. If the neurons are stimulated, they continue to be viable for new synapse growth. Sprouting constitutes A reorganization of those connections Damage may cause compression, breakage, cell death and lost function Sprouts form

Restorative Improve skills through use of exercises and drills Good potential for learning Optimizes function through dynamic,aggressive rehab Treatment may integrate multiple functional tasks and can involve more than one discipline Few environmental modifications are required For CVA, mild TBI, Brain tumor, reversible Dementia, stage 3 dementia

Restorative Skill Building Repetition Stimulus/cue hierarchies Major skill is maintaining attention with out distraction and with distraction – In a young child: attending following simple commands Listening to a story initiating interaction – In an older child or teen – finishing a written task – In an adult- making a grocery list

Memory Therapy Techniques Restoration/Traditional Model Chunking: grouping things Organization –Categories, semantic meaning, similarities, visual images(notebook of pictures) Rehearsal Sequences, places, facts, situations Elaboration/linking Taking what one already knows and linking it in some way to what one wants to remember (say out loud)

Categorization Program Constantinidou, 2001 A: Recognition and categorization of common objects Level 1:Perceptual feature training Different perceptual features Level 2: same and different Level 3 functional categorization Level 4 Analogies dog:puppy Cat: kitten reserved : personable introvert:? Level 5: abstract categorization opposites, similarities B New Category learning tasks Categorizing by 2 parameters

Compensatory Assumes that the client cannot recover completely With caregiver/family Functional strategies calendars list making communication notebook phone usage Verbal Routines

Compensatory Patient may require cueing to optimize performance Provide training in those compensatory strategies Alternate forms of communication External compensatory strategies Internal compensatory strategies For Alzheimer’s Disease, TBI, Degenerative neurological, Dementia stage 4+

Adaptive Focus of the treatment is on adaptation of the environment and caregiver education Identifies strategies to prevent further dysfunction For Dementia stage 5-6 Moderate to severe TBI Degenerative neurological diseases

Cognitive Functions’ Worse Enemies Stress and Anxiety Depression Metabolic Diseases Thyroid gland, diabetes, organ failures, alcoholism Vitamin B-12 deficiency Infections Drugs ADHD Hypothyroidism Aging