Family-friendly strategies for the Rehabilitation of Attention and

Family-friendly strategies for the Rehabilitation of Attention and Memory Dr. Brian Waldron Senior Clinical Neuropsychologist

Overview of the presentation… • Anatomy of the Human Brain • Attention & Concentration – Types and Strategies • Learning & Memory – Types and Strategies • Problem Solving – Models and Strategies • Decision making in the Human Brain

Be mindful that… • Brain injuries are permanent and lifelong. There are very few easy fixes and there are no miracle cures • People with ABI and families can learn new skills • People with ABI have strengths and these can be built on • Families have strengths and these can be built on • Some information we discuss today will apply to your family members and some information will not apply to your family member with an Acquired Brain Injury.

Acquired Brain Injury - ABI • Traumatic Brain Injury - TBI • Cerebral Vascular Accident (Stroke) – CVA – Ischaemic Stroke (clot / blockage) – Intracerebral haemorrhage (bleed inside the brain) – Subarachnoid haemorrhage (bleed inside the skull) • Encephalitis • Meningitis • Anoxia • Tumour – Neurosurgery – Chemotherapy – Radiotherapy • All can effect the frontal lobes and cause executive problems. • All can effect the temporal lobes and cause memory problems. • What about CT and MRI Scans?

MRI Scans and Brain Damage

Aspects of Brain Functioning • Two Hemispheres & Four Lobes • (Montreal Neurological Institute Video) • • Frontal Lobe Temporal Lobe Parietal Lobe Occipital Lobe • Windows Phone / I-Phone / Android – 3 D Brain is a free app that helps visualise brain areas

Anatomy of the Human Brain

Executive functioning encompasses • Attention & Concentration – Types of Attention* – Brain Areas – Strategies • Learning & Memory – Types of Memory – Brain Areas – Strategies • Problem Solving - Models of Problem Solving - Brain Areas - Strategies

Attention & Concentration: Subtypes • Sustained Attention – concentrating over lengthy periods of time. • Selective Attention – concentrating on one thing and filtering out / ignoring distractions. • Divided Attention – concentrating on two things at the same time – requires a degree of flexibility. • There are significant interactions between attention systems in the brain – particularly with Alertness*.

Executive functioning encompasses • Attention & Concentration – Types of Attention – Brain Areas* – Strategies • Learning & Memory – Types of Memory – Brain Areas – Strategies • Problem Solving - Models of Problem Solving - Brain Areas - Strategies

Areas: Frontal Lobe – Orbitofrontal Circuit Social Restraint, Empathy, Inhibition of Interference

Executive functioning encompasses • Attention & Concentration – Types of Attention – Brain Areas – Strategies* • Learning & Memory – Types of Memory – Brain Areas – Strategies • Problem Solving - Models of Problem Solving - Brain Areas - Strategies

Attention & Concentration: Strategy 1 Strategy: Reduce Internal Distractions • • Tiredness Daydreaming Anxiety* Wellbeing -Do not stay on one point too long -Work at a fair speed -Set definite goals (SMART) -Reward for reaching goals Strategy: Reduce External Distractions • Noise • Movement • Interruptions -Remove radio & television -Avoid busy locations -Turn off your mobile phone**

Attention & Concentration: Strategy 2 • Strategy: Sustain Attention for longer by Self Alerting Procedures • (Robertson et al. , 1995). • Eight participants suffering from chronic unilateral left neglect (caused by damage to the parietal lobes) were trained to sustain their attention by a self alerting procedure. • This training reduced the amount of left sided neglect and increased the participants ability to sustain attention over time.

Attention & Concentration: Strategy 2 • Strategy: Sustain Attention for longer by Self Alerting Procedures • (Robertson et al. , 1998). • Eight participants suffering from chronic unilateral left neglect (caused by damage to the parietal lobes) were asked to judge if a line appeared on the left of a computer screen or on the right of the screen. • When prompted with a loud tone (which increased alertness and attention ) just before the lines appeared the amount of left neglect was reduced.

Attention & Concentration: Strategy 3 • Strategy: Use Auditory Cues to prompt Attention on Multitasking • (Manly et al, 2002). • Ten participants were asked to try and do some of each of five tasks within 15 mins. The total time to complete all of the tasks would exceed an hour. The task emphasises person's ability to monitor the time & switch between tasks. • Without the external auditory cues, people with ABI performed significantly more poorly than age and IQ-matched control volunteers, a common error being to continue performing one task to the detriment of beginning other tasks - or - allocating sufficient time to other tasks.

Attention & Concentration: Strategy 3 • When exposed to interrupting tones, however, 1. the people with ABI’s performance was both significantly improved 2. and no longer significantly different from the control group on important variables • Use the Alarm on your phone and keep hitting ** Snooze **

Executive functioning encompasses • Attention & Concentration – Types of Attention – Brain Areas – Strategies • Learning & Memory – Types of Memory* – Brain Areas – Strategies • Problem Solving - Models of Problem Solving - Brain Areas - Strategies

Learning & Memory: Subtypes • James (1890) • Atkinson and Shiffrin (1968) – Short term memory – Long term memory • Tulving (1985; 1989 a; 1989 b) – Long Term - Semantic memory – Long Term - Procedural memory – Long Term - Episodic memory • Lynch and Yarnell (1973)**

Executive functioning encompasses • Attention & Concentration – Types of Attention – Brain Areas – Strategies • Learning & Memory – Types of Memory – Brain Areas* – Strategies • Problem Solving - Models of Problem Solving - Brain Areas - Strategies

Learning & Memory: Brain Areas

Neurological Studies of Memory • Neurogenesis in Monkeys (Gould, 1999) • Neurogenesis in Humans (Gage, 1998) • Alzheimer’s (Arriagada et al. 1992) • PTSD (Bremner et al. 1995) • London Taxi Drivers (Maguire et al. 2000)

Neurogenesis in Monkeys (Gould, 1999)

Neurogenesis in Humans (Gage, 1998)

Executive functioning encompasses • Attention & Concentration – Types of Attention – Brain Areas – Strategies • Learning & Memory – Types of Memory – Brain Areas – Strategies* • Problem Solving - Models of Problem Solving - Brain Areas - Strategies

Learning & Memory: Strategy 1 Strategy: Internal Memory Strategies • Don’t try to “learn off” what you don’t understand. • Do relate new information to what you know already. • Break the information down into several parts. • Take a break after 30 or 40 minutes (max). • Do not try to take in too much information at once. • Look at the information a number of times (learning curve)

Learning & Memory: Strategy 2 Strategy: External Memory Strategies / Memory Aids • A written Diary or Journal • Wall-charts / Wall-calendar • Notes (The yellow sticky variety) • Mobile Phones** • Microsoft Outlook** • Electronic Memory Aids** • **Reminders help with Prospective Memory

Lessons from the RAVLT • Capacity of Short Term Memory – The STM research from the 1960 s said 7± 2 • Learning Curve • Primacy Effect • Recency Effect • Interference Effect – Proactive Interference – Retroactive Interference

Prospective Memory / Delayed Intentions • The word 'remember' is used in two different ways: • That we must do - prospective memory • That we have done - retrospective memory • Einstein and Mc. Daniel (1990) distinguished between two components of any prospective task. • • The first is a retrospective encoding of the action to perform and it's context (time and place in which it is to be performed). • The second task is to complete the intended action in response to the proper context.

Ellis (1996) 5 -stage model of PM. • A Sequence of five stages in Prospective Memory – First is the encoding of intention and action. – Second is a retention interval – Third is a performance interval – Fourth during the PI the intended action is carried out – The performance is evaluated • Factors that influence the successful “realisation of delayed intentions” include. . . – – – The complexity of tasks to be performed Strengths of intention to perform the action Variable retrieval contexts

Substitutive Training vs. Compensation • Wilson in a comment on restorative training (1998) concluded, "There is a distinct lack of evidence that retraining through exercise is effective" (p. 477). • Cognitive retraining "fails to address the functional manifestations of cognitive problems as experienced by brain injured patients in real life, that is, it tackles impairments as measured by tests rather than disabilities as measured by problems encountered in real life" (p. 477). • Sohlberg and Matter’s Prospective Memory Training Program • A shift in emphasis has occurred.

Substitutive Training vs. Compensation • Wilson and Powell (1994) comment "rather than ask the question, 'How can I improve this person's memory? ' it is usually more profitable to ask, 'What is the best way for this person to retain new information" (p. 694). • The goal is to train the patient to use his intact abilities in developing strategies to overcome his deficits (Finset and Andresen, 1990). • Capitalise on old learning from before the ABI

Diary Training: Sohlberg & Mateer, 1989 • Acquisition of the skill is the initial stage. This is where the person acquires the very basic competencies of how the system works. Names and purposes of each section in the diary are taught. This is facilitated through question and answer sessions and the explicit declarative knowledge is tested prior to training in the second phase. • The second stage application refers to learning where and when to employ the new set of skills. It allows clients to practise the newly acquired skills in a particular context. Clients were taught to use their diaries in guided role-plays. • The third stage was adaptation and “corresponds to that learning stage wherein an individual demonstrates the ability to adapt and modify skill use to accommodate novel situations” (p. 875).

Electronic Aids: Waldron et al 2012

Executive functioning encompasses • Attention & Concentration – Types of Attention – Brain Areas – Strategies • Learning & Memory – Types of Memory – Brain Areas – Strategies • Problem Solving - Models of Problem Solving* - Brain Areas - Strategies

A Cognitive Model of Problem Solving Encode Problem in Working Memory Search Long Term Memory for Solutions Make an Attempt at Solving Problem Compare new situation with Goal state Try Again Done

Areas: Frontal Lobe: Dorsolateral Circuit Planning & Organisation, Fluency, Mental Flexibility

Executive functioning encompasses • Attention & Concentration – Types of Attention – Brain Areas – Strategies • Learning & Memory – Types of Memory – Brain Areas – Strategies • Problem Solving - Models of Problem Solving - Brain Areas - Strategies*

Planning & Problem Solving- Strategy 1 Strategy: Apply time management skills “Time is life, it is irreversible and irreplaceable” Lakein, 1973 Prioritise your Tasks • What I have to do – List 10 things you have to do and pick the most important 5 things for this week • What I want to do – List 10 things you want to do and pick the most important 5 things for this week

Planning & Problem Solving- Strategy 2 Strategy: Set goals that are as well defined as possible • • • Specific Measurable Achievable Realistic Time limited • Short Term, Medium Term, Long Term. • Webb & Glueckauf (1994). Goal Setting • High Involvement vs. Low Involvement

Planning & Problem Solving- Strategy 3 Strategy: The 5 WH System • • • What? Who? Where? When? Why? How?

Planning & Problem Solving- Strategy 4 What is the problem? What are possible solutions? Solution 1 Solution 2 Solution 3 What is the best solution? Try that approach. Did it Work? Try a different solution if needed Solution 4

Phineas Gage after 1848 incident

Computer Reconstruction of Injury

The Somatic Marker Theory • The Emotions of Decision Making in the Human Brain • Decision making often occurs in the face of uncertainty about whether one's choices will lead to benefit or harm. The somaticmarker hypothesis is a theory of how decisions are made in the face of uncertain outcome (Naqvi et al, 2006). • The key idea in theory is that 'marker' signals influence the processes of response to stimuli, some of which occur consciously and some of which occur non-consciously (Damasio, 1994, 1996, 1999). • Reasoning is guided by the emotion felt when considering our action’s consequences. • Take note of your emotions when considering options and pay attention to any “bad feelings”.

References • Atkinson, R. C. & Shiffrin, R. M. (1968). Human Memory: A Proposed System And It's Control Processes. In K. W. Spence & J. T. Spence (Eds. ), The Psychology Of Learning And Motivation: Advances In Research And Theory (Vol. 2, pp. 89 -195). New York: Academic Press. • Damasio, A. R. (1994). Descartes' Error: Emotion, Reason, and the Human Brain, London: Penguin Books. • Damasio A. R. (1996). The somatic marker hypothesis and the possible functions of the prefrontal cortex. Philos Trans R Soc Lond B Biol Sci. 351(1346): 1413 -20. • Damasio, A. R. (1999). The Feeling of What Happens: Body and Emotion in the Making of Consciousness, London: William Heinmann. • Einstein, G. O. & Mcdaniel, M. A. (1990). Normal Ageing And Prospective Memory. Journal Of Experimental Psychology, Learning, Memory And Cognition, 16, 717726.

References • Ellis, J. (1996). Prospective Memory Or The Realisation Of Delayed Intentions: A Conceptual Framework For Research. In M. Brandimonte, G. Einstein & M. Mcdaniel (Eds. ), Prospective Memory: Theory And Applications (pp. 1 -22). New Jersey: Lawrence Erlbaum Associates. • Finset, A. & Andresen, S. (1990). The Process Diary Concept: An Approach In Training Orientation, Memory And Behaviour Control. In R. L Wood & I. Fussey (Eds. ), Cognitive Rehabilitation In Perspective (pp. 99 -116). Hove (UK): Lawrence Erlbaum Associates. • Gage, F. (1998). Neurogenesis in Humans. Nature Medicine, 4, 1313. • Gould, E. (1999). Neurogenesis in adult macaque monkeys. Science, 286, 548. • Heppner, P. P. , & Krauskopf, C. J. (1987). An information-processing approach to personal problem solving. The Counseling Psychologist, 15, 371 -447. • Lakein, A (1973). How to Get Control of Your Time and Your Life, New York: New American Library.

References • Lynch, S. & Yarnell, P. R. (1973). Retrograde Amnesia: Delayed Forgetting After Concussion. American Journal Of Psychology, 86, 643 -645. • Manly, T. , Hawkins, K. , Evans, J. , Woldt, K, & Robertson, I. H. (2002). Rehabilitation of executive function: facilitation of effective goal management on complex tasks using periodic auditory alerts, Neuropsychologia, 40, 271– 281 • Naqvi, N. , Shiv, B. & Antoine Bechara (2006) The Role of Emotion in Decision Making: A Cognitive Neuroscience Perspective, Current Directions in Psychological Science 15 (5), 260– 264. • Maguire, E. A. , Gadian, D. G. , Johnsrude, I. S. , Good, C. D. , Ashburner, J. , Frackowiak, R. S. J. & Frith, C. D. (2000). Navigation-related structural change in the hippocampi of taxi drivers. Proceedings of the National Academy of Science USA 97(8), 4398– 4403. • Newell, A. , & Simon, H. A. (1972). Human problem solving. Englewood Cliffs, NJ: Prentice Hall. • Robertson, I. H. , Tegner, R. , Tham, K. & Lo, A. (1995). Sustained Attention Training for Unilateral Neglect: Theoretical and Rehabilitation Implications. Journal of Clinical and Experimental Neuropsychology, 17(3), 416 -430

References • Robertson, I. H. , Mattingley, J. B. , Rorden, C. & Driver, J. (1998). Phasic alerting of neglect patients overcomes their spatial deficit in visual awareness. Nature, 395, 169 -172 • Tulving, E. (1985). How Many Memory Systems Are There? American Psychologist, 40, 385 -398. • Tulving, E. (1989 a). Remembering And Knowing The Past. American Scientist, 77, 361 -367. • Tulving, E. (1989 b). Memory, Performance, Knowledge And Experience. European Journal Of Cognitive Psychology, 1, 3 -26. • Waldron, B. , Grimson, J. & Blanco-Campal, A. (2012). Effectiveness of an unmodified personal digital assistant as a compensatory strategy for prospective memory failures in adults with an ABI. Irish Journal of Psychology. • Wilson, B. A. (1998). Traumatic Brain Injury. In D. W. Johnston & M. Johnston (Eds. ), Comprehensive Clinical Psychology, Volume 8, Health Psychology. Oxford: Pergamon Press.

References • Wilson, B. A & Powell, G. E. (1994). Neurological Problems, Treatment And Rehabilitation. In S. J. E. Lindsay & G. E. Powell (Eds. ), The Handbook Of Clinical Adult Psychology (pp. 688 -704). London: Routledge. • Webb, P. M. & Glueckauf, R. L. (1994). The effects of direct involvement in Goal Setting on Rehabilitation Outcome for Persons with Traumatic Brain Injuries. Rehabilitation Psychology, 39(3), 179 -188.