Cognitive Training & Remediation

At BrainX we offer cognitive training and cognitive remediation for patients with neurocognitive disorders. It doesn't matter whether you have sustained a head injury, have suffered a stroke, or have a neurodevelopmental disorder like ADHD or a neurogenetic disorder. All our programs are aimed at building and compensating for specific skills, no matter what the disorder. 

Cognitive training has been around for many years. We are all familiar with physical therapists that teach motor sequences to improve patients mobility after brain impairment. We are familiar with occupational therapists that instruct patients on how to complete tasks of daily living after stroke or head injury. Speech therapists for over a hundred years have been teaching children how to improve their language skills following a language delay, or rehabilitate language after brain injury. All these therapies require one-on-one intensive instruction. 

Cognitive training involves systematic instruction, and people with cognitive weaknesses benefit most from structured training that includes explicit models, a minimisation of errors during initial acquisition, strategies to promote learner engagement, and carefully guided practice to enhance mastery, maintenance and generalisation across contexts.

There are three approaches to neuro-remediation that we conduct:

(1) Restorative Approaches: A treatment approach that aims to decrease impairments in cognitive ability and improve core cognitive skills. For example, attention training can be conducted to improve attention capacity. 

(2) Compensatory Approaches: A treatment approach that teaches people to develop strategies to maximise function. For example, for people with memory issues, they can be taught to use external aids such as a diary, calendar or a to-do-list. 

(3) Metacognition training: Metacognition means 'knowing about knowing', and refers to the processes involved in appraising one's knowledge and skills, including both the ability to monitor one's thinking, as well as the ability to use that information to regulate your own behaviour. Poor metacognition (ie. lack of insight) is a huge barrier to remediation, and mindfulness of thoughts, skills and behaviour is a fundamental factor in being able to initiate change. 

Huge leaps in the knowledge of neuroplasticity are occurring in neuroscience, and this has massive implications for the field of cognitive training and remediation.

ATTENTION TRAINING

Attention is not a unitary skill. Sustained attention refers to the ability to focus on something for a lengthy time period. This can include both auditory sustained attention, the ability to listen to information over a sustained period, as well as visual sustained attention, the ability to look at something for a sustained period. If the attention issues appear visual, it is important to rule out visual issues such as convergence insufficiency and tracking issues, as ocular motor issues can present as visual attention weaknesses, however, treatment needs to be at the eye muscle level, not at the brain-based level. Auditory processing issues can in some cases case similar weaknesses to auditory sustained attention, however usually cognitive testing can rule this out as a case as tests of auditory attention do not usually require high levels of auditory processing. 

Other aspects of attention include visual attention span and auditory attention span. This is the ability to hold both visual and auditory information in one's short-term memory store ready for processing. 

Switching attention and working memory are other cognitive skills that can underlie functional attention weaknesses and are often closely related. Working memory is the ability to hold information in one's short-term memory store and then manipulate this information mentally. Switching attention is the ability to switch between two tasks smoothly and quickly, without losing where one is up to. If working memory is weak and information quickly decays from memory, often switching attention will also be affected.

Divided attention is the ability to processing two streams of information simultaneously. This may include a stream of auditory information and visual information (eg. as seen when a teacher or lecturer talks about something in a picture).

Once the core attention weakness is determined, exercises will then be performed to build that specific skill. at first we usually train on abstract and simple tasks, building the capacity to perform this skill. Then we give real-world examples that involve these skills, especially in areas that are personally relevant. As item become more complex we will also build in strategies to compensate for weaknesses in order to reduce the processing burden. 

Lastly, we work upon metacognition through exercises of mindfulness in order to improve the ability to know when you are not paying attention so that you are aware more about when to pull your attention back. We all have moments when we get distracted (eg. when surfing the net) and then after a while we realise we have drifted off doing irrelevant things. Mindfulness is about realising when you have drifted off more quickly and having techniques to pull yourself back and refocus. This is an important aspect of attention training. 

 

EXECUTIVE TRAINING

No matter how smart people are, poor executive skills will tend to result in significant levels of under-performance. A person who cannot find their notes for study or their tools for work, and does not know when things are due, or is able to judge how long things will take, will tend to lead chaotic lives. This can lead not only to poor performance at school (for kids) or in the workplace (for adults), but also can lead to depression and low self-esteem (when not able to produce the results they want) as well as anxiety (always worrying what will go wrong).

Executive training involves the training of various skills associated with being able to start and complete a task. These skills involve planning the task, breaking down the task into small units, determining the sequence of steps to complete the task and then monitoring whether you are on track. This involves training in time estimation (we often under-estimate how long is needed) as well as time management (setting a schedule). Fundamental to good executive skills are the ability to use a diary, to-do-list and set priorities. We tend to work with what technology the person has available and what they feel comfortable with. Many people also struggle with task initiation (ie. just sitting down to start a task) and for this we train people in strategies to boost both motivation and drive. Organisational skills are also key to strong executive skills and we often need to train people to have good organisational tools and ways to keep their workspace neat and files ordered.

We tend to make the executive training very specific to the person's circumstances. Children in primary school often have less executive demands, but we try and teach them to become less dependent on their parents to get ready in the morning, remember to take in things to/from school and generally keep well organised. It is the high school students who often benefit most from executive training as the structure of primary school falls away and the students need to be more autonomous in managing their time, subjects and randomly assigned homework. We have a specific program for students who are entering grade 7 who already have identified weakness in executive skills. We also have a high school program that not only trains executive skills but combined these skills with general study skills and memorisation techniques (for exams).  In adults we train people according to the areas in which executive skills affect their lives. Where is is running late to appointments, forgetting to pay bills, having issues in the workforce, or having issues managing further study. All our programs are tailor made for the specific needs of the individual according the the executive pre-assessment.

Remote treatment of neurocognitive disorders

Remote Tele-remediation: Can it work?

By admin | September 10, 2018

Tele-remediation is defined as “Providing remediation services to patients at their location/home using information and communication technologies.” Tele-remediation is considered as an alternative and innovative approach to health care, which has been made possible with rapid advancement in technological and remediation methods in the recent years. The current technological approach provides a wide range of…