Diagnosis and Therapy Approaches for the Speech Language

Pathologist

Cognitive Functions

Domains of Cognitive Function1.Attention2.Memory Processes :short and long term

3.Verbal language4.Categorization :Means of incorporating new info and organizing info in the brain

5.Abstract thought

Constantinidou, Thomas, & Best (2004)

1.Attention

Orienting NetworkGuides 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 NetworkAbility 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 dinnerTime schedules

Executive Network

FlexibilityCapacity to multitaskSwitch attentionOrganize sequencesFor 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 NetworkMemory is organized with respect

to time and contentsShort term/working memoryLong 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. CategorizationAssigning objects or events

into groupsInterrelated with other

cognitive processesObject recognitionProblem solvingDecision makingSustained attention tasks that require sorting

Learning and memoryCategorization is critical to problem solving in order to consider solutions

Components of CategorizationRecognition 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

ReasoningDecision making andProblem 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 tableAttach at the end

TBI, CHI, CVA , Progressive Aphasia , Dementia, Developmental , Autism spectrum, CP, LD, may each be faced with challenges:

AttentionOrganization and categorization

difficultiesLearning difficultiesMemory deficitsInformation processing

impairmentsExecutive functioning deficits

Reasoning, decision making, problem solving

Psycho social- anxiety and depressionSocial-Communication difficultiesReceptive 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 TestCognitive Abilities Screening TestFunctional Communication ProfileLanguage -Cognitive-

Communication WAIS III-Digit Backward and

Symbol SubtestBoston Diagnostic Aphasia Exam-

has subtests which test cognitive functions

Stroop Color Word TestNote: 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 buildingRepetitionStimulus/

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, theycontinue to be viablefor new synapse growth.Sprouting constitutesA reorganization of thoseconnections

Damage may cause compression, breakage, cell death and lost function

Sprouts form

Restorative

Improve skills through use of exercises and drills

Good potential for learningOptimizes function through dynamic

,aggressive rehabTreatment 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

Memory Therapy TechniquesRestoration/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 ProgramConstantinidou, 2001A: Recognition and

categorization of common objects

Level 1:Perceptual feature trainingDifferent perceptual featuresLevel 2: same and differentLevel 3 functional categorization Level 4 Analogies

dog:puppy Cat: kitten reserved : personable introvert:?Level 5: abstract categorization opposites, similarities

B New Category learning tasksCategorizing by 2 parameters

Compensatory

Assumes that the client cannot recover completely

With caregiver/familyFunctional strategies calendars list making communication notebook phone usageVerbal Routines

Compensatory

Patient may require cueing to optimize performance

Provide training in those compensatory strategies

Alternate forms of communicationExternal compensatory strategiesInternal compensatory strategiesFor 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 5-6Moderate to severe TBIDegenerative neurological

diseases

Cognitive Functions’ Worse Enemies

Stress and Anxiety

DepressionMetabolic

DiseasesThyroid gland, diabetes, organ failures,

alcoholism

Vitamin B-12 deficiency

InfectionsDrugsADHDHypothyroidi

smAging