Many people may
not know what
cognitive training is or
what benefits can be gained for those
who have lost cognitive functioning and
even for those individuals who just want
to keep their mind fresh and exercised.
Dr. Joseph A. Sandford, head of the ADD
Treatment Center is Richmond, VA,
believes one of the most cost-effective
and beneficial therapy tools sits right
in the homes of many people today.
The Computer.
A growing number of health professionals
and home-based individuals are
discovering that their computers can be
an indispensable partner in a cognitive
behavioral therapy approach.
Dr. Sandford is
the author of
Captain's Log, a
35-program set of computerized cognitive
training exercises for helping to
improve attention,
concentration, inhibition, memory,
visual-motor
coordination and
self-esteem in ADHD, learning disabled
and brain injured individuals. He has
now released
SoundSmart to help more
specifically in the areas of
auditory attention
and processing.
Since many
professionals want to know about this
computerized cognitive behavioral
approach, Dr. Sandford was asked to
share his therapy and training methods
for this article.
Dr. Sandford:
Cognitive training consists of a variety
of exercises designed to help improve
functioning in areas such as sustaining
attention, thinking before acting,
visual and auditory processing,
listening, reading - areas in which ADHD
individuals often experience
difficulties. If an individual is having attentional or learning problems,
tutoring or drill and practice in
academic areas are often not effective.
The principle underlying cognitive
training is to help improve the "core"
abilities and self-control necessary
before an individual can function
successfully academically. The exercises
"drill for skill" directly in the areas
where basic specific cognitive
difficulties occur.
Dr. Sandford:
The
Captain's Log system
which I use for cognitive training
contains a wide range of exercises
designed to improve visual and auditory
attention, concentration, inhibition,
memory and visual-motor coordination.
These exercises can be incorporated
within a therapy framework for ADHD
individuals that focuses on improving
emotional and behavioral self-control.
Here are some examples of how this can
be done:
1) The exercises
may be used to train individuals who are
impulsive, impatient and frustrated to
learn to wait repeatedly while engaging
in a positive stress reducing behavior
such as muscle relaxation techniques or
diaphragmatic breathing.
2) The therapist
makes use of distracters to reinforce
focused attention in a distracting
environment.
3) The exercises
can be set for success to improve
self-esteem and help develop a positive
attitude towards learning.
4) The system can
be set up to push a client to the limit.
The therapist can then intervene and
help the individual to find strategies
for dealing with frustration and small
failure experiences. The task can then
be broken down into easier components,
and the individual can practice on each
of these. Using this approach, the
therapist can help the individual learn
to work through anger and frustration
and achieve a breakthrough toward
emotional stability.
5) Individuals can
be encouraged to "brake" in order to
learn information. Using the programs,
they can be taught to engage in
brainstorming, problem-solving
techniques and to reflect on how they
can improve. This can clinically
reinforce the value of stopping,
thinking and then proceeding with a
strategy based on a better understanding
of what the task requires. Through these
efforts, an individual can learn that
"if you continue to try you can
succeed."
Dr. Sandford: Since this approach
requires repetition and one-to-one
instruction, the computer is the easiest
and most cost-effective way to implement
this type of program. The use of the
computer can also facilitate self-esteem
and increase the fun of learning which
has often been lost by children with
ADHD. Children get immediate
reinforcement, which works best for
children with ADHD; the therapist gets
immediate scoring and the ability to
record progress. The computer can
provide both structured exercises and a
reward system in the form of games.
Dr. Sandford:
There are a number of different ways in
which cognitive training can be utilized
and the cost covered within the current
health and educational systems. In some
cases schools can be encouraged to
purchase the system in order to help
facilitate learning for individuals with
learning difficulties and/or ADHD.
Unless the foundation is laid for the
cognitive processes necessary for
learning, many of these individuals are
turned off by school because of repeated
failure experiences. By boosting their
cognitive abilities with cognitive
training one can often turn these
individuals into better learners and
more self-confident people. So one
approach is to lobby your school to add
cognitive training to special education
classes.
Therapists can
also invest in the cognitive training
system to enhance their regular therapy
program. The goals of therapy are to
improve emotional and behavioral
functioning through therapeutic
interaction with the client. However,
talk psychotherapy with ADHD children is
often very limited in its results.
Research supports that a multi-modal
approach to therapy is best in the
treatment of ADHD. Following this idea,
therapists use medication, behavioral
interventions, parent training and
self-control enhancing techniques.
Computerized cognitive training fits
well in this framework, as it enables
patients to act out their feelings and
interact with the therapist, who takes a
positive and supportive role helping
them to practice and accomplish tasks
which are fun but require sustained
attention, effort, self-control and
problem solving techniques.
Most insurance
companies do not cover directly for
cognitive training services for ADHD per
se. In cases where parents reject
working with medication, I make it clear
to them that they may to need to invest
in two or three therapy sessions per
week and that insurance companies may
not fully cover this intensive training.
Some parents are willing and able to
invest in their child's well-being to
the degree that they will make this
commitment.
Another way that
cognitive training can be reimbursed is
through special services offered by
clinicians. This past summer I offered a
special group training program. By
having eight individuals participate
simultaneously, each working at his/her
individual computer station, and
administered by a technician under my
supervision, it was possible to keep the
cost low. The services were paid for
directly by the parents, and cost less
than a one-to-one tutor. The program was
especially beneficial in getting people
who have children with mild to moderate
cognitive problems or undiagnosed ADHD
into the health care system. Many people
are willing to explore training who may
have a more negative approach towards
psychotherapeutic intervention. I have
found that many children with learning
problems also have emotional or
behavioral problems. By setting up a
training center I was able to help
identify these children and establish a
rapport and positive interaction with
the parents. As a result, those children
who needed more intense one-to-one
therapeutic help where the parents had
held off or not recognized the needs
were now getting services. In a
practical sense, for a clinician, such a
program can be a useful investment as a
way to help your practice grow.
Dr. Sandford:
Recently I worked with an adolescent boy
who was very rebellious about making the
effort to sustain his attention and
continue trying. In order to facilitate
his cooperation, I worked with his
parents on ways to encourage him to stay
on task. A token system was initiated in
which he lost money when he "acted out."
Cognitive training was used to teach him
how to sustain his effort and how to
continue trying to improve. As a result
of the therapy, his oppositional and
resistant behaviors significantly
declined, and his self-esteem and
willingness to make efforts greatly
improved. He learned to cooperate better
with authority figures and became more
positive in his interactions with
others. In the following school year, he
was found to be much more compliant with
his teachers. Before the training, he
participated in soccer and did not make
any goals; after the training program he
was reported by his parents to have
become much more active in his efforts
and would often make many goals in a
game.
In another case a
12-year-old autistic child with
attention problems and severe
intellectual impairments was unable to
perform self-directed activities. When
given instructions by his parents, he
was unable to prepare a sandwich for
himself. After he had completed my
summer program, he was able to follow
his parents' directions and prepare
lunch for himself. He had learned to
focus his attention and concentration
and sustain his efforts on the
sequential task required for meal
preparation.
I used
auditory cognitive
training (SoundSmart)
to treat an adolescent client who was
severely impaired in the area of
auditory attention. He often did not
listen when homework assignments were
given and would "space out" during
class. At the end of the training he was
able to discontinue his Ritalin
medication and still maintain adequate
functioning in terms of his ability to
attend and concentrate on verbal
information presented in class and to
remember to write down and complete his
homework assignments.
Dr. Sandford: Once I had the
opportunity of meeting B.F. Skinner who
was an inspiration to me in that he had
developed a teaching system early on
which had progressive levels of training
and provided immediate feedback. At that
time, technology had not developed to
such a degree that low cost devices such
as personal computers could be used.
When this became feasible, I felt that
the computer provided me with a teaching
tool which I could use to carry on the
work of B.F. Skinner in providing an
interactive, positive system which
provides immediate feedback.
Dr. Sandford: I also use these
standard methods. However, the
Captain's Log programs
provide me with an extra powerful tool
to add to my multi-modal approach. To
make an analogy, a surgeon can use
either a surgical knife or a laser tool
to perform his surgery. It is necessary
to make an incision in either case.
However, healing is much faster and less
painful with the laser tool.
Captain's Log is my version of
the laser tool.
