Attention Training Procedures

Alice Medalia , in Encyclopedia of Psychotherapy, 2002

2.B. Learning Theory and Attention Remediation

The employ of techniques such as shaping, errorless learning, and frequent positive feedback prove the influence of behavioral and learning theory. Errorless learning refers to the careful titration of difficulty level and then that the patient learns without resorting to trial and fault, and has a positive experience with increasing challenge. Shaping and positive feedback are integral components of the social learning approach of Paul and Lentz, and have been used extensively to decrease mal-adaptive behaviors in the chronic, highly regressed psychiatric patient. Although Paul'southward social learning approach was not adult for utilize with cognitively impaired individuals, methods such equally shaping and positive reinforcement have since been found effective for treating attending harm. Learning theory has also indicated some of the factors that promote generalization of skill. Inside the remediation exercises, target behaviors demand to exist paired with multiple cues, ideally in various contexts, and then that the behavior volition exist elicited in multiple settings. In attention grooming this occurs when the focus/execute response is paired with auditory, visual, and social cues in a variety of tasks. Patients who do multiple tasks that exercise the ability to focus and quickly execute a response are more likely to amend than those whose training is limited to repetitive execution of one task.

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Treatment of Severely Impaired, Amnestic Patients

Helmut Hildebrandt , in Cognitive Rehabilitation of Retentivity, 2019

2.1 Errorless Learning and Vanishing Cues in Memory-Dumb Patients

Following the German guidelines, in patients with chronic severe-memory disorders (as divers above) the method of errorless learning should be used to teach specific knowledge, procedures, and daily routines. Specific knowledge to be trained with the method of errorless learning may business the names of significant others, the routes to be followed to get from "A" to "B", simply also may start with preparation a uncomplicated, appropriate behavior in response to a cue (e.g., if an alarm clock is starting to ring). On a theoretical level, one may be skeptical that patients with a complete amnestic syndrome can learn annihilation, because the definition of their condition is that they are unable to practise so. On this basis, it should be evident that the learning process used to care for amnestic patients differs from the learning process used in the treatment of patients with balmy or moderate retention impairments. In the example of amnestic patients, teaching strategies should not presume that the patients possess a conscious retentivity trace ("declarative memory") or the internal possibility of an evaluation concerning the correctness of a response. On the opposite: The necessity of a reevaluation of incorrect responses should be avoided. The reason for that is that patients with amnesia ofttimes learn incorrect responses as correct (just because the wrong answer becomes more familiar and the patients lack the possibility to suppress the feeling of familiarity by recollection, see the results of Schacter, Verfaellie, Anes, and Racine (1998) and Budson et al. (2002)).

Errorless learning is a method that aims to foreclose patients from giving wrong answers. It is a type of shaping and is based on a very frequent repetition of the "question" and the correct "answer". Thus, it is based on implicit or procedural learning, which is often unimpaired or less dumb than explicit learning in amnestic patients. Typically, the patient is confronted with the critical stimulus (e.thousand., a pic of a pregnant other) as well as the name of this person, and they are tasked with repeating the written name. The procedure is repeated multiple times ("massed restudy") to ensure that the patient learns the association between motion-picture show and name.

One very important (although intensively discussed) method of errorless learning is the method of vanishing cues. Vanishing cues means that the corporeality of data given to provide the correct answer is reduced over a menstruation of time. A typical example is to learn the name of a person by first presenting the total name, then the full name except the terminal letter, and so the full name except the two last letters, etc. (Fig. Iv.2.1). A reduction of the number of letters merely occurs when a correct respond is given. If the answer is right, the next letter of the alphabet is removed, if information technology is incorrect, one additional alphabetic character is added.

Fig. IV.2.1

Fig. Iv.2.1. An example for the vanishing cues method.

The method of vanishing cues is not restricted to exact learning. One may also outset with the last part of a path and cue the patients to plow in a specific direction until all directional changes take been learned.

Some authors contend that the method of vanishing cues is non part of errorless learning, because reducing the cues may lead to errors. An early on review of Kessels and de Haan (2003) even argued that the method of vanishing cues does non help amnesic patients at all. The reason proposed for the absenteeism of any result of vanishing cues is that the patients are allowed to estimate, and therefore to perform errors. Indeed, the method of vanishing cues does involve run a risk that patients perform some error. However, carefully observing patients for signs of hesitation and intervening in such situations by providing more cues volition prevent errors to some caste. Typically, more contempo reviews on the method of vanishing cues (Ehlhardt et al., 2008; Ptak, der Linden, & Schnider, 2010) reveal more promising results than the early on review of Kessels and de Haan (2003).

Regardless of whether ane uses the method of vanishing cues or massed full repetition of a behavior for pedagogy amnestic patients skills or information, learning with these methods is slow. Furthermore, there is a problem when eliminating the last cue, every bit the cue is essential to initiate the whole sequence in the heed of the patients. On the other mitt, these methods can be extremely effective in teaching specific behavioral performances every bit long equally the context is static. Glisky and Schacter (1989) managed to teach a patient with a dense amnesia the power to transfer data from forms into data files, although the patient had no experience in using a computer. To reach that goal, the steps necessary for starting the figurer, initiating the program, transferring the important pieces of information, etc., were analyzed into small substeps, which were taught to the patient by the method of vanishing cues. Afterwards one-half a twelvemonth of grooming, the patient was able to perform the transfer of information as fast as healthy controls and therefore received a half-time position at the visitor. The report of Glisky and Schacter (1989) was a single instance study. Oudman et al. (2013) showed through a series of unmarried instance studies that patients with Korsakoff'due south syndrome can learn to use a washing machine. Trojano, Moretta, and Estraneo (2009) documented in a unmarried case written report that it is possible to teach a young patient suffering from a astringent polytrauma to use an center-tracking communication arrangement. After the handling, he was able to interact with the surround through that organization, simply the patient never remembered that he had already used the centre tracker in the past.

In about of the studies, the method of errorless learning was used to teach a specific slice data such as a name of a person or the use of an instrument. Errorless learning and vanishing cues may besides be used to teach severely-retentivity-impaired patients to use an external memory aid, which may help the patients to gain more than independence in organizing their everyday lives. Sohlberg and Mateer (1989) demonstrated in a single case report that it is possible to teach the employ of an external retentivity assist (a retentivity book) to a immature patient with anterograde amnesia afterward herpes encephalitis. Like Glisky and Schacter (1989), they subdivided all steps of using the memory book into substeps and taught the correct execution of these substeps to the patient. By applying the method of vanishing cues, they helped her to transfer these steps into everyday life. Table IV.2.1 shows the unlike handling phases including transfer training. Fig. 4.ii.ii documents the progress made in pedagogy the patient to use a retentiveness book in the form of a single case experimental design plot. The figure also shows that information technology took more than 50 treatment sessions earlier the patient could handle the task, despite a high level of engagement of relatives and therapists from other professions in the training.

Table Iv.2.1. Steps to teach a severely memory-dumb patient to use a memory book

Training stage Clarification
Acquisition Larn names, purpose and use of each notebook section via question/reply format.
  Efficiency goal 100% accuracy on questions for 5 consecutive days.
Application Acquire appropriate methods of recording in notebook via function play situations.
  Efficiency goal 100% accuracy of response to three role play situations with no cueing on two consecutive days
Accommodation Demonstrate advisable notebook use in naturalistic settings via community grooming.
  Efficiency goal Receive a score of four for 2 situations on two consecutive days

(From Sohlberg & Mateer, 1989)

Fig. IV.2.2

Fig. Iv.2.2. Unmarried case experimental design documentation of the progress made in educational activity the severely-retentiveness-impaired patient the utilize of a retentiveness book.

 (From Sohlberg M. M., & Mateer C.A. (1989). Training utilise of compensatory retention books: a three phase behavioral approach. Journal of Clinical and Experimental Neuropsychology, 11(6), 871–891. https://doi.org/ten.1080/01688638908400941.)

Pitel et al. (2006) demonstrated in two single case studies that the method of errorless learning tin also be helpful in treating patients with combined memory and executive function disorders. Information technology should be mentioned that all these studies relied on single example studies, and information technology is therefore unclear how many patients might manage with the help of errorless learning to employ an external memory assist on their own and how many might not. B. A. Wilson (2013) argued that external memory aids (such as memory books) are the right choice for patients with pure amnesia, as the errorless learning technique allows them to learn their usage fairly reliably. E. de Joode, van Heugten, Verhey, and van Boxtel (2010) and E. A. de Joode, van Heugten, Verhey, and van Boxtel (2013) reviewed publications on external memory aids and attempts to teach memory aids to patients with acquired brain injuries and ended that increasing the functionality of an external memory aid (as from NeuroPage to a Smartphone, i.e., from a monodirectional to an interactive apparatus) will tend to overwhelm severely-retention-impaired patients. As at that place is no systematic group report to show the number and types of patients that will benefit from the introduction of an external memory aid, the conclusion of Due east. de Joode et al. (2010) is important for the topic of this chapter. In general, information technology is of import to land that there are currently no randomized controlled trials (RCTs) involving patients with complete anterograde amnesia as to whether they can larn to utilize an external retentivity aid past errorless learning and how far such aids are able to amend independence in everyday life. Therefore, the evidence level for teaching this grouping of patients the contained use of external retentivity aids past errorless learning is Level Iv: It is a clinical consensus which still awaits a RCT. As has been argued before, the evidence level for education external retentiveness aids to moderately to mildly impaired patients is higher and may be scored as Level IIa. Nevertheless, in the absence of any other possibility to treat severely-memory-impaired patients, i should try to teach them the utilise of external memory aids.

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Managing Memory Deficits to Optimize Function

Glen Gillen EdD, OTR, FAOTA , in Cognitive and Perceptual Rehabilitation, 2009

ERRORLESS LEARNING

Errorless learning is a learning strategy that is in contrast to trial and fault learning or errorful learning. Interventions using an errorless learning approach are based on differences in learning abilities. Information technology is typical for people with memory impairments to call back their own mistakes as results of their ain action more successfully than they recall the corrections to their mistakes occurring via explicit ways (e.thousand., a therapist's cue). In other words, people may remember their mistakes but not the correction. With errorless learning a person learns something by saying or doing information technology, rather than being told or shown by someone. In addition, the person is not given the opportunity to brand a fault (i.east., there are no mistakes to be remembered). The hypothesis is that reduction or prevention of incorrect or inappropriate responses facilitates memory functioning. The technique is straightforward and involves preventing clients from making whatever errors during learning via physical and exact support or cues from the therapist. In other words reducing the use of trial and error and avoiding mistakes. Errorless learning techniques likewise have been successful with those living with apraxia (see Chapter 5).

Although errorless learning continues to be tested equally a possible technique for the rehabilitation of clients with retentivity harm, the cognitive processes responsible for improved memory of information are not clear. 69 Two theories accept been proposed, both of which focus on the distinction between implicit and explicit memory. Tailby and Haslam summarize that when errors occur, those with retentiveness impairments tend to repeat the same errors across learning trials. 69 This possibly occurs because errorful learning relies on explicit retentivity processes, which those with retentivity impairments cannot apply (seeTable 9-2). Explicit processes permit for monitoring and elimination of errors, and without this process a person cannot modify responses during learning. Any error performed by retention-impaired clients during errorful learning may be repeated, resulting in reinforcement of an incorrect response.

All the same, implicit memory may be spared in those with retentiveness impairments. Tailby and Haslam state that "Implicit learning is well served nether errorless learning conditions, as past eliminating errors during learning the strongest response will exist the correct response and this would be the only i reinforced." 69 The second theory proposes that the benefits of errorless learning are supported by residual explicit memory equally opposed to implicit processes.

Evans and colleagues 18 presented nine experiments, in three study phases, which tested the hypothesis that learning methods that prevent the making of errors ("errorless learning") volition lead to greater learning than "trial-and-fault" learning methods among those who are retention impaired as a outcome of caused brain injury. Errorless learning techniques include the post-obit:

•

Providing the correct answer immediately: For example, when showing a moving-picture show of unfamiliar face, the therapist would enquire, "What is this person'southward name? His name begins with M; his proper noun is Michael." The authors found that this technique was benign for remembering names by outset alphabetic character–cued recall equally compared to learning names by trial and error.

•

Astern chaining: Used to teach multistep tasks, in this approach the therapist shows or prompts all of the steps of the job. On the next trial, all of the steps except for the last one are demonstrated or prompted and the person being taught the skill must demonstrate information technology. After each trial, prompts are withdrawn and the technique progresses until all of the steps are learned. The authors found that this technique was beneficial for learning names by starting time letter–cued recall as compared to trail and fault.

•

Forward chaining: Also used to teach multiple step tasks, the therapist prompts or demonstrates the kickoff stride on the offset trial, the first 2 steps on the second trial, and continues until the whole sequence is remembered.

•

Combined imagery with errorless learning: Associations between faces and names were taught by having he subject field create a mental paradigm based on facial features; for example, the wave in the person'due south hair looks similar a W; his name is Walter. The authors documented improved complimentary think of names using this technique.

The authors' results suggest that tasks and situations that facilitate retrieval of implicit memory for the learned material (east.g., learning names with a first letter cue) will benefit from errorless learning methods, whereas those that require the explicit recall of novel associations (such as learning routes or programming an electronic organizer) will not benefit from errorless learning. The more severely retentivity-impaired clients benefited to a greater extent from errorless learning methods than those who were less severely memory dumb, but the authors cautioned that this may apply only when the interval between learning and recall is relatively short.

Wilson and coworkers 79 compared errorful and errorless learning in the teaching of new information to neurologically dumb adults with severe memory problems. Those with retentivity impairment scored significantly college under the errorless status when learning word lists. In improver, the authors examined errorless learning via five single case studies in which five men with severely impaired memories learned data analogous to that needed in everyday life such equally learning names of objects and people, learning how to program an electronic aid, remembering orientation items, and learning new items of general noesis. In each case, errorless learning was superior to errorful learning.

Andrewes and Gielewski ii documented a successful render-to-work case study of a 28-twelvemonth-onetime adult female with memory loss secondary to herpes simplex encephalitis. The described intervention embraced principles of errorless learning and the breaking down of tasks into procedural routines advisable for nondeclarative retentivity. The intervention highlighted the extensive use of environmental cues including a procedural folder, which led to habit learning and unsupervised piece of work in filing, checking in books on a computer, and shelving of books. The person described in the case gained employment as a office-time banana librarian in the library of a police business firm. Similarly, Hunkin and associates 32 documented the case of a 33-yr-old man living with severe memory loss secondary to viral encephalitis and a resultant seizure disorder. Techniques of errorless learning were used to teach him word-processing skills. After training he was able to employ the skills acquired to perform the same tasks without whatsoever instruction.

Clare and colleagues half dozen examined half dozen subjects with dementia (Alzheimer blazon) who received individually tailored interventions, based on errorless learning principles and targeted at a specific everyday retentivity problem. 5 of the subjects showed significant comeback on the target measures (e.thousand., learning names of those in a social club, remembering personal information, using a calendar) and maintained this comeback up to 6 months later. The authors concluded that it is feasible to intervene with everyday retentiveness problems in the early on stages of dementia of Alzheimer type and that errorless learning may be useful in addressing these problems.

A meta-analysis of errorless learning for treating memory loss was conducted past Kessels and de Haan 36 and documented a large and statistically significant effect size for errorless learning treatment. In addition, no significant effect size was demonstrated for the vanishing cues method (i.e., teaching a skill by fading cues over fourth dimension). It should be noted that the majority of studies that were analyzed used laboratory-type impairment measures such as word lists, face-name associations, and the like.

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Neurocognitive Evolution: Disorders and Disabilities

Pascale Piolino , ... Isabelle Jambaqué , in Handbook of Clinical Neurology, 2020

Developmental amnesia

The care of patients with DA has been the discipline of several works based on reeducation techniques in adults with an amnesic syndrome, such as facilitating the encoding or retrieval of information, exploiting intact memory systems (semantic memory, implicit memory), or developing the surround with supports (posting notes, calendar, alarms, photos, etc.). A child with marked episodic retention deficits must perform deliberate learning exclusively relying on semantic retentivity, reasoning, and deduction skills. Specific learning techniques known equally "errorless learning," which favor the acquisition of semantic noesis despite a severe episodic retentiveness disorder, have too proven to be relevant in DA. Several studies in children accept proposed a personalized protocol to come across whether DA can benefit from multimodal facilitation techniques, such as blurring or blending for learning, errorless learning, double encoding and manipulation of material for characteristics learning, or repetition of information. For instance, the errorless learning method was tested in two children with DA on four successive sessions using the double encoding method (texts and images) and retrieval (naming and multiple-selection recognition) regarding 8 unknown concepts (e.g., the name of an creature and its characteristics) ( Guillery-Girard et al., 2004; Martins et al., 2006). The results showed learning capacities, despite the absenteeism of retentivity of the different learning sessions, but learning was slower than in a group of healthy children. Calculation the blending technique appears particularly useful, since the denomination tasks did not significantly differ in the two DA patients from those of controls. In general, all the studies confirmed that DA patients tin can acquire new learning but demand more sessions to attain the level of controls. In improver, how the patients are questioned (recognition vs recall) facilitates admission, or not, to this new knowledge by reducing the involvement of episodic memory. Therefore, families and schoolteachers tin can do good from these preparation methods that facilitate explicit memory in DA. In everyday life, more than more often than not, it is noticeable that DA patients need external aids and social-environmental support, especially for managing contextual constraints and all changes in routines. Proposing classic learning techniques and daily-life accommodations tin be the basis of quality of life improvements in DA and be compatible with future professional activities and social life. Finally, as episodic memory deficit in DA also involves the breakdown of episodic autobiographic memories, a preparation program may too propose strategies to facilitate the storage of personal memories across the unabridged lifespan to improve social adaptation, autonomy, and sense of self. Some compensatory strategies were spontaneously prepare up by Valentine to improve her social adaptation. Indeed, she developed the habit of taking pictures of all the significant events in her life. Thus when asked about these, she could bring nigh alter by providing details and, in fact, describing the photos by memory. Sensecam has also been used to help severe anterograde amnesic patients to go on in mind some of their new personal experiences. Sensecam is a vesture camera that takes photos automatically of personal experiences from a first-person perspective, conceived as an private "Black Box" recorder. The repeated viewing of these previously recorded images tends to elicit the formation of personal semantic memories in children who take marked episodic memory difficulties (Pauly-Takacs et al., 2011).

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Traumatic Brain Injury☆

B.A. Wilson , in Reference Module in Neuroscience and Biobehavioral Psychology, 2017

Conclusions: An Integrated Approach to Cognitive Neuropsychological Rehabilitation

In the calorie-free of the discussion above, and the fact that feelings affect how we think and how nosotros carry, we demand to recognize that cognition should not be divorced from emotion, motivation, or other noncognitive functions. Consequently, an integrated program should address not simply cognitive functions only also social, emotional, functional, and melancholia difficulties. Programs should focus on the everyday difficulties, that is, the functional consequences of encephalon injury, rather than treat problems identified by tests. Effectiveness should not exist evaluated by improvements on test results simply on functional achievements in everyday life.

We need a broader theoretical spectrum on which to base our rehabilitation programs. Wilson (2002) proposed an integrated model combining many of the different influences needed for successful rehabilitation. We need to strengthen the interaction betwixt theory and clinical ascertainment. Theory tin sometimes predict which methods might piece of work but clinical observation is often required to tell us how best to implement the theory. For case, work on errorless learning in the rehabilitation of amnesic patients ( Baddeley and Wilson, 1994) grew out of theoretical piece of work on implicit retentivity. The implementation of errorless learning principles in clinical rehabilitation, however, requires behavioral observation and analysis at an private patient level (Wilson et al., 1994).

We need to ensure proper evaluation of neuropsychological rehabilitation programs. Nosotros should recognize that RCTs are not the only way to evaluate rehabilitation. There is increasing recognition that RCTs are of limited value in determining its efficacy. Every bit Andrews (1991) says, (the RCT) "is a tool to exist used not a god to be worshipped." He goes on to say that the RCT is excellent where (one) the blueprint is uncomplicated, (2) marked changes are expected, (3) the factors involved are relatively specific, and (4) the number of additional variables likely to affect the event are few and can be counterbalanced out. This is quite unlike the situation in rehabilitation. Modest grouping or cohort studies, crossover designs, and single case experimental designs (SCEDS) are possible (Tate et al., 2008; Perdices and Tate, 2009).

Research should be at a number of levels of specificity. At the near general level are questions such as "Is this approach effective?" and "What are the cost consequences of providing and not providing neuropsychological rehabilitation?" These questions are, perchance, best answered through collaborative research possibly involving a health economist. At a more specific level we need to evaluate different rehabilitation strategies such as the comparison of two (or more than) methods to improve attention or teach new information. This is where modest grouping or accomplice designs are potentially very valuable. At the greatest level of specificity is the evaluation of an individual client's response to treatment. Is this patient changing and is the change due to spontaneous recovery or to our intervention are 2 of the most important questions in rehabilitation and ones that every person engaged in clinical practice should attempt to answer.

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The Use of Transcranial Direct Electric current Stimulation for Cognitive Enhancement

Chung Yen Looi , Roi Cohen Kadosh , in Cognitive Enhancement, 2015

Explicit Learning

Explicit or declarative learning processes involve memories that can exist consciously recalled, accompanying implicit learning processes that are automatic or unconscious (Squire, 1982). For example, when you recall tDCS and cognitive enhancement in a week's time, you will remember that it was achieved past reading this articulate and well-written chapter. It is the active conquering of skills and/or cognition whereby individuals tin can explain how they proceeds such skill and/or noesis. To date, effects of tDCS have been explored mainly in memory for discussion lists or objects and memory for spatial location. In studies that used word lists, Marshall et al. (2004) used a unique stimulation protocol that involved a pulsed stimulation technique during sleep: A-tDCS was applied to bilateral dlPFC and pulsed on/off for 15-s intervals during the first xxx   min of tiresome-wave sleep to increase memory of word lists. They found a modest, but pregnant increase in the number of words recalled from a list that had been learned the day earlier, but no effects on procedural memory. The authors concluded that tDCS could have modulated neuronal plasticity by generating deadening oscillatory neural activeness.

Hammer et al. (2011) explored the effects of tDCS over the left dlPFC in two conditions of learning: errorless and errorful learning of new German nouns. After the encoding stage, participants either performed in the errorless or errorful status. In the errorless condition, they were required to use the word in a judgement, whereas in the errorful condition, they were provided with the starting time three letters of words in the list and were required to think from retentiveness the discussion from the list. The latter task differs from the quondam because it includes both retrieval and reconsolidation. The authors plant a trend toward increased learning from errorful learning with A-tDCS, although the effect was not significant, and significantly decreased learning after C-tDCS in the same status. They did not observe whatever effects of tDCS in the errorless learning condition. They ended that C-tDCS decreased reconsolidation in this type of word list learning task.

In a series of word memorization tasks, Javadi and Walsh (2011) practical sham stimulation, A-tDCS, and C-tDCS over the left dlPFC in healthy participants. They establish that, during encoding, A-tDCS improved and C-tDCS impaired later retention recognition. They showed that this effect is site specific: A-tDCS to the M1 had no effect on later recognition. During recognition, C-tDCS impaired recognition compared with sham stimulation, and A-tDCS led to a tendency toward improved performance in recognition. Overall, these findings show that the furnishings of tDCS on exact memorization and the left dlPFC are polarity- and site-specific.

There are also studies that focus on spatial retention. In addition to the study by Floel et al. (2012) (reviewed in the section "Studies of the Elderly"), Clark et al. (2012) investigated the effects of A-tDCS on object detection in a computerized virtual environment using a inconspicuous object detection task of the type performed past military personnel in urban settings (Effigy 12.3). They applied either 0.i or ii   mA of A-tDCS over the right junior cortex during the first 30   min of an hour-long discovery task. Participants were tested on their functioning immediately before and later on training and once more 1   h later. The authors found that stimulation at a higher current of ii   mA was linked to increased functioning for all test stimuli and greater accurateness for target detection sensitivity compared with 0.1   mA. This finding suggests that the effects of tDCS are influenced by current dosage.

Figure 12.three. Examples of stimuli used past Clark et al. (2012) in functional magnetic resonance imaging (fMRI) and transcranial straight current stimulation (tDCS) learning studies.

(A) Examples of stimuli with and without concealed objects. Only four of the six scenes include subconscious objects. Two of these four scenes with concealed objects incorporate subconscious enemy soldiers, and the other two contain hidden bombs. The difficulty of object detection was defined past the size and distinctiveness of objects. (B) The fMRI learning written report paradigm followed by xiii participants. Each participant was scanned using fMRI at the novice stage using 100 static scenes without feedback. This was followed past up to 90   min of preparation per day, whereby participants press a button to bespeak whether they observed a concealed epitome in a series of static images, with each response followed by a brusk feedback video. Participants trained consecutively until they achieve an intermediate level of performance (>78% correct responses on two consecutive training blocks) and were scanned again. The training continued for vii of these participants until they achieved 95% accuracy, when they were scanned for the last time at the expert level. (C) The paradigm used for behavioral tDCS learning studies; each session was preceded by a pretest involving viewing static scenes without feedback, followed past 4 training blocks of 60 trials each. Participants received tDCS v   min earlier their training began for 30   min, followed by additional training without tDCS, for a total of i   h of training. Immediately subsequently preparation, a posttest was conducted, followed by an hour break and a final delayed posttest.

 Figure adjusted with permission from Elsevier. (This figure is reproduced in color in the color plate department.)

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Amnesia☆

M. Lafleche , D.J. Palombo , in Reference Module in Neuroscience and Biobehavioral Psychology, 2017

Approaches to Treatment of Amnestic Disorders

The treatment of memory disorders aims at enhancing 24-hour interval-to-day memory functioning and routine so as to increase an individual's level of independence. The choice of treatment will depend on both cerebral and noncognitive factors. Noncognitive factors to exist considered include psychosocial context (eg, family situation, educational background, lifestyle habits) and emotional factors (eg, level of insight, motivation, neuropsychiatric symptoms). Of critical importance among these factors are level of insight and motivation. Research has shown that interventions are unsuccessful in patients who fail to appreciate that their retention is dumb and/or who are unmotivated. In these patients, efforts should initially focus on increasing level of insight and/or motivation. Cognitive factors that must be taken into account include premorbid abilities and skills and postmorbid neuropsychological deficits, including a clear depiction of those areas of retention that are impaired and preserved. Within the context of a holistic individualized approach, a retentiveness remediation program can be adult based on the current agreement of the processes that back up learning and memory.

Several treatment approaches for densely amnesic patients capitalize on nondeclarative memory processes because this form of retention remains intact in about patients. The "vanishing cues" technique is an example of a treatment method that recruits preserved implicit perceptual memory processes to teach patients domain-specific facts or concepts. The technique takes reward of patients' preserved power to complete studied items in response to word fragment cues. In a typical vanishing cue paradigm, patients are given a definition and are and then presented with every bit many letters as is necessary to produce the target word. With training, the letter cues are gradually reduced until the patients can spontaneously generate the sought afterward information. Success has been achieved using this technique in educational activity patients computer-related vocabulary, concern-related terms, and novel concepts. Learning by means of this technique is slow and laborious but tin pb to surprisingly good retention, particularly if the information to exist learned uses a knowledge base that is already familiar to the individual. However, a caveat arises from the inherent reliance of the vanishing cues method on the perceptual cues given during learning. As a upshot, generalization has ofttimes been limited, and benefits have been found to be all-time when the information is used in situations similar to those in which learning occurred.

Attending to training contexts may be important when using techniques that take reward of preserved implicit memory processes. Because amnesic patients take no recollection of learning episodes, they neglect to remember their mistakes and consequently fail to benefit from ongoing error correction. Instead, incorrect responses made during learning are often unconsciously repeated, leading to errors becoming primed and more likely to be repeated afterward. To avoid the perpetuation of errors through priming, some investigators have emphasized the importance of "errorless learning" for patients who have explicit retentiveness impairments. In errorless learning, the possibility of making errors is eliminated by using cues and prompts or by providing the right answer. The arroyo has met with some success in pedagogy memory-impaired patients both new skills (eg, the apply of a memory volume, the programming of an electronic organizer) and new knowledge (eg, the learning of new words). Errorless learning is thought to operate by strengthening residue explicit memory, either alone or together with implicit retentiveness. Its applicability as a method to facilitate learning appears to be wide and promising because errorless learning principles can be applied to a variety of remediation methods.

Other treatment approaches capitalize on preserved procedural learning. Through repetition, skills and habits that are important for activities of daily living or occupation can be taught. Such skills can range from simple assembly tasks to more complex multistep tasks such every bit learning to type. A variety of compensatory aids (eg, notebooks, scheduling books, diaries, alarms) and augmentative technologies (eg, computers, personal digital administration, paging systems) rely on procedural memory. The notebook is an example of a low-tech assist. Information technology is usually created at the early on phase of rehabilitation and contains sections aimed at drilling overlearned personal information (eg, date of nascence, historic period, address), information about immediate family members (including their telephone numbers), daily schedules, and a daily record of activities. The volume is tailored to the individual and can be gradually increased in complexity. Electronic organizers, the most favored external memory help among normal individuals, are now likewise being used by memory-dumb patients. Training in the utilise of such engineering science requires lengthy practice sessions, within and exterior the rehabilitation environment, to foster generalization. Because the acquisition of new skills is time-consuming for anybody involved, conscientious consideration needs to be given as to whether an electronic device is appropriate for an individual before investing the time and effort to teach the skill. Factors that would argue confronting such training include dense amnesia associated with poor insight, lack of initiative, dumb visual attention, poor motor control, and limited problem-solving skills. Patients who are practiced candidates for this technology are more often than not younger, take feel in using electronic devices, and have accomplished higher educational levels. Devices used premorbidly are preferable because familiarity increases the likelihood that they will exist used finer outside the clinic.

The preceding examples illustrate approaches that focus on preserved retention systems to teach new skills and habits. Another approach focuses on enhancing impaired forms of memory to improve solar day-to-day episodic memory past means of internal strategies. Internal strategies require awareness of the learning method and recall of the strategy itself; therefore, they are of limited use to patients who are moderately or densely amnesic. However, they are useful for patients who have mild memory deficits secondary to dumb effortful encoding or retrieval, who accept good awareness of their deficits, and who have adequate motivation. These patients are more likely to generalize their training to situations that go beyond the dispensary setting. Examples of internal strategies include mental retracing, feature–name clan, and verbal elaboration by means of a story or an association, all of which are skills that promote the utilize of imagery. The choice of technique will depend on the memory process that is targeted for remediation. For example, techniques that focus on strengthening encoding, and therefore storage, are constructive at remediating consolidation problems. Story elaboration is effective in linking together a list of unrelated words through the evolution of a scenario that features the target words. The use of verbal associations is often effective in recalling a surname.

In all of these instances, repeated use of the strategy is important, and spaced repetitions, at different times and in different contexts, generally increment the likelihood that data will be learned and become conceptually integrated within a matrix of quondam memories. Strategies that are virtually effective when the arrears is at the level of the strategic processes that enhance encoding are those that increase the organizational construction of incoming data. For case, learning how to "chunk" incoming information is helpful in streamlining and organizing that information. Organizing information co-ordinate to themes or categories can besides structure learning so that a thematic cue can serve to trigger recall when necessary.

More than than 50   years ago, the early clinical findings with H.One thousand. and other patients informed the theoretical understanding of the functional systems that comprise homo memory. Current cerebral neuroscience has evolved from those early findings and now, in turn, tin inform clinical approaches to remediation that enable amnesics to part more than effectively in their daily lives.

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Managing Apraxia to Optimize Function

Glen Gillen EdD, OTR, FAOTA , in Cognitive and Perceptual Rehabilitation, 2009

Errorless Completion and Preparation of Details

Goldenberg and Hagmann 29 tested a method of specifically training ADL for those living with apraxia. They specifically examined spreading margarine on a slice of bread, putting on a T-shirt, and brushing teeth or applying hand cream. Each of the activities was trained for one week past an occupational therapist. Those non being trained were carried out with maximal support and without specific training. When an activity was beingness trained, the focus was on errorless completion of the whole activity. As opposed to trial-and-mistake learning, errorless learning or completion is a technique in which the person learns the activity by doing information technology. The therapist intervenes to prevent errors from occurring during the learning process. This technique also has been used for those with retentiveness impairments (see Chapter 9). Support from the therapist was provided at diverse stages of the activeness until the customer could movement through the area of difficulty on his or her own. Specific interventions included the following:

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Guiding the hand through a difficult attribute of the activity

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Sitting beside the customer (parallel position) and doing the same activity simultaneously with the client

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Demonstrating the required action and enquire the client to copy it afterwards

In addition, the intervention focused on grooming of details. This was aimed at directing the customer's attention to "the functional significance of unmarried perceptual details and to critical features of the deportment associated with them." Specific difficult steps of the activity were trained using this approach. To promote knowledge of object utilise, key details of ADL objects were explored and examined such as the beard on a toothbrush and the teeth on a rummage. Deportment connected to the details were then practiced (due east.grand., searching for and positioning a shirtsleeve for a person with dressing difficulties) outside of therapy. Specific necessary motor actions also were adept in other activities and contexts (due east.m., squeezing paint from tubes as a similar action as squeezing toothpaste).

Goldenberg and Hagmann 29 tested this intervention by examining 15 clients with apraxia with repeated measures of ADL function. Success of therapy was based on the reduction of errors of specific tasks. The authors differentiated between reparable errors (the client succeeds in continuing the job) or fatal errors (the client is unable to proceed without help or the job is completed but did non fulfill its purpose). Across the whole group, the number of fatal errors decreased significantly, whereas the number of reparable errors did not significantly modify. The authors besides noted several clinically relevant observations:

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Even though therapy led to significant improvements in trained ADL, there was no comeback in ADL if left to spontaneous recovery.

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Long-term success of the intervention was based on continued practice and ADL participation after completion of the intervention.

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The success of the intervention seemed to exist based on teaching clients "instructions of use" related to specific objects.

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Specific preparation can restore independence for trained activities.

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There was no generalization from trained to untrained tasks.

In terms of the lack of generalization to untrained tasks, past definition the errorless component of the intervention is in fact chore specific and training of details is aimed only at object utilise errors seen in those living with apraxia and not other difficulties encountered by this population. 27 This may represent a limitation of the intervention, merely farther research is necessary.

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Learning and Retentiveness

Richard Morris , ... Tim Bussey , in Cognitive Systems - Data Processing Meets Brain Science, 2006

half-dozen.2 Cognitive Engineering science

Given these are non insignificant hurdles, many cognitively oriented neuroscientists believe that we will demand cerebral engineering alongside pharmaceutical engineering. You practise not read so much nigh cognitive engineering science in the newspapers as nearly new drugs, just ill-informed journalism does non make information technology whatever less important.

The idea is to have advantage of what has been learned about how data is encoded, stored, consolidated and retrieved – as described in this summary. The awarding of cognitive engineering takes willpower to put its principles into action; it's harder than but taking a pill – but at that place are grounds to recall that information technology may work ameliorate.

Experiments take shown that better encoding of data at the fourth dimension of learning improves retention – past thinking about things carefully in an attentive mode and establishing connections with established knowledge. Psychologists call this the encoding-specificity principle.

Spacing of learning sessions helps long-term memory; neuroscientists link this to the conditions of relevant cistron-activation and the synthesis of plasticity-proteins. Frequent reminders ensure that information is retrieved at a time when memories are fragile, then associatively interconnected in semantic retention. This engages the consolidation process: neural-network engineers volition readily link this to the process of effective interleaving of information into distributed networks.

Recent rehabilitative piece of work using errorless learning in patients with retentivity loss is a skilful example of how it can be help to understand the mechanisms past which we larn and retain new memories. This approach stemmed from studies of learning in animals. It was pioneered by Baddeley and Wilson (1994), who explored whether memory-impaired patients would learn amend if they were prevented from making mistakes during the learning process. The scientific rationale behind this hypothesis was that amnesic patients are much more probable to rely upon implicit memory – a system that readily acquires information simply does not discriminate between what is right or incorrect (all responses being equally familiar). The initial study by Baddeley and Wilson revealed better learning in amnesic patients who were encouraged to pursue an errorless learning strategy.

Researchers interested in retentivity rehabilitation were quick to take up this technique. It has also been shown to be successful, at to the lowest degree in the curt-term, in patients with Alzheimer's disease.

Case V.J., who was profoundly amnesic, could simply name on boilerplate 2-3 members of his social order. After grooming, all the same, V.J. could name all 11 members and astonishingly, maintained this level of performance for up to nine months (Clare et al., 1999).

Some patients with semantic dementia show a different profile. Example D.M. attempted to learn new vocabulary by practising with a children'southward dictionary at home. D.M. showed a remarkable improvement in his ability to produce words in response to a category label after practice (even outperforming controls). Disappointingly, he could not sustain his new level of performance without connected practice. Although D.Grand. was likewise using an errorless approach, he may accept shown a different pattern to V.J. because he did non take a fully functioning semantic system in which to embed his new learning (Graham et al., 1999). Interpreting the differences between these 2 patients would be impossible without knowing something about the human relationship between episodic and semantic memory.

Recognizing the operating principles of the different types of retentiveness is as well essential – you lot will never learn a skill past merely hearing almost it, even though this works fine for episodic memory. The employ of external memory aids in amnesic patients has been relatively unsuccessful until recently, predominantly because their functions are complicated to larn. As Wilson (2003) aptly notes: 'the very people who need external memory aids are oftentimes the people who are most likely to have difficulty in learning how to use them'.

To circumvent this problem, Hersh and Treadgold (1994) adult a paging arrangement (NeuroPage), in which a schedule of personalized reminders and cues is entered into a calculator and subsequently, sent to the pager on a designated twenty-four hour period and time. The device is simple and portable – the user has only to larn to operate 1 large push (to confirm receiving the message).

2 clinical studies of the efficacy of NeuroPage accept shown that many amnesic patients, and their families, can benefit significantly from this approach. For example, (Evans et al., 1998) report a patient, R.P., who had suffered a stroke seven years earlier, and had issues carrying out tasks. R.P. would spend too much time in the bath because she kept forgetting where she was in a sequence of washing. Using a checklist and NeuroPage, R.P. could break free from her stereotyped routines and bath in a reasonable time. This subsequently allowed her to attend a day centre, which had been impossible earlier, thereby releasing her married man from the daily monotony of constant reminders.

The use of technological aids such every bit pagers and computers in memory rehabilitation is probable to increment, in part due to developments in information technology but also as in that location are more memory-dumb people in the population. The main disadvantage of a scheme like NeuroPage is that it requires a primal calculating resource to organize, manage and transmit the messages, taking away some of the inherent flexibility in these types of systems.

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Applications in Diverse Populations

Oliver C. Mudford , Gill McGrane , in Comprehensive Clinical Psychology, 1998

9.12.3.ten.4 An even less intrusive treatment?

An example of taking a new approach that avoids coercive interactions to reduce a common problem beliefs, with mothers as change agents, has been demonstrated by Ducharme and his colleagues (Ducharme et al., 1994; Ducharme & Popynick, 1993; Ducharme & Worling, 1994 ). Ducharme and Popynick assessed a process for errorless learning of compliance with four children with developmental disorders. Offset, parents rated the frequency with which their children complied with mutual requests on a four-indicate scale from "almost ever complies" (level 1) to "rarely complies" (level four). Second, the frequencies of compliance for 12 requests at each rated level were empirically evaluated in the families' homes. Following assessment of baseline compliance at each level, the third phase involved training mothers to provide level 1 requests only and to reinforce their kid's compliance with praise and/or physical contact (east.thou., hugs and kisses). Mothers were taught not to repeat the same asking or to provide any consequences for noncompliance. When high (> eighty%) and stable levels of compliance had been accomplished with level 1 requests, mothers were instructed to innovate level 2 requests gradually, for example, 14 level ane requests interspersed with seven level 2 requests. In the following session, the proportions of requests at each level were reversed and, in subsequent sessions, even greater densities of the level 2 requests were included until loftier and stable compliance to these requests were achieved. Likewise, level 3 and level iv requests were introduced. Trouble behaviors reduced markedly when compliance increased. For example, level 4 requests which had been associated with tantrums and assailment on 51% of trials in baseline reduced to 10% following the intervention. Because that these behaviors were not targeted directly, their reduction showed a valuable side effect of the mother-mediated compliance training.

Ducharme et al. (1994) replicated their previous study with four children with developmental disabilities and a nondisabled sibling of 2 of those, all of whom were referred for lack of compliance. The therapist'due south input with each mother was reduced from 34 hours in Ducharme and Popynick (1993) to 17 hours, on boilerplate, by abbreviating the initial empirical assessment procedure and assessment of intervention. There was no turn down in the clinical significance of outcome with these refinements. Both studies assessed consumer satisfaction with the intervention. The mean score was 6.3 out of a maximum possible of 7.0, indicating that mothers found the intervention highly satisfactory. The authors note that therapist involvement in errorless compliance training tin be implemented with fewer (5 or six) sessions either at a clinic or in the family dwelling house when a case is not intended to provide enquiry data for publication.

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