Neuropsychonline Weblog

Task 1 - Sequenced Recall { Digits [ visual ]} - Upon first presentation of this task, allow the patient to work without assistance until s(he) reaches their limit. Then introduce the idea of compensatory skills and working memory. Point out the limited capacity of working memory and the necessity to organize and reorganize data to get it into a format that maximizes the amount of information that can be manipulated in working memory. Some compensatory skills include talking aloud, chunking and repeating information. You may need to model these techniques. Point out daily activities in which these same compensatory skills could come into play. Emphasize that for compensatory skills to become a natural part of daily functioning they must be practiced to the point that they occur without conscious thought or effort.

Problem solving skills are those skills that allow us to analyze the facts of a situation so that we can use that analysis to come to a conclusion about the situation. The name, itself, is the best description. We are faced with a problem that we must overcome or solve to acheive our goal. The situation can be as simple as deciding what clothes to wear today or as complex as an algebra or calculus math problem. Although problem solving skills well deserve their own category, they require the use of the other cognitive skills, particularly those of attention and executive functioning that are needed to recognize facts, gather them together and organize them.

Two of the main types or methods of problem solving are 1) deductive reasoning and 2) inductive reasoning. With deductive reasoning the conclusion is ensured by the facts. This means that when you have gathered and analyzed the facts of a situation you are certain that the conclusion is the true solution. For example, Jack is spraying Tim with the water hose, therefore Tim is wet. We deduce Tim is wet because we see Jack spraying him with the hose. However, if we just saw that Tim was wet, we could not, with certainty, deduce that Jack sprayed him with the water hose. Tim might have fallen into the pond.

With inductive reasoning, analysis of the facts can allow one to predict the conclusion or solution with high probability that the conclusion is correct but without a guarentee the conclusion is correct. The facts might support a particular conclusion but they do not ensure it. Suppose we walked up to Tim’s house and saw that he was wet and also saw that Jack was holding a water hose. We could analyze the facts and conclude that Jack sprayed Tim with the hose. This is inductive reasoning because with just those facts we could not be certain. Tim could have fallen in the pond while Jack was watering the flowers.

In daily life we probably use a combination of deductive and inductive reasoning to come to conclusions and solve problems. If we learn to gather, organize and analyze facts better we could become better and more accurate problem solvers.

We can gather facts just by observing situations. There may or may not be enough facts to just see or hear to solve the problem. If this is the case we may have to engage in more investigative actions to discover more facts. We may have to ask questions. We may have to try to recreate situations to better see how the facts played out. We may have to think up hypothetical conclusions and test them to see if our “educated guess” is consistent with the facts we have gathered. Trial and error learning might fall into this problem solving strategy.

Organizing information better might enable us to see facts we missed when the information was not so organized. This might involve putting information into groups or in a certain order. We may have to group one way and then regroup it another way to make the facts clear to us. We may have to compare one fact or one group of facts with another to see what is true or what goes together or does not go together. Making a decision that some facts cannot go together helps us to come to good conclusion just a much as determining what does go together. For example, there are four children of different heights and without seeing them I must determine which is shortest and which is tallest. Through my investigation of the facts I find that Jim is taller than Bill, Kathy is shorter than Jane and Bill is taller than Jane. Rather than just trying to answer the question of who is tallest or shortest I can help myself by determining who cannot be tallest or shortest. Since Jim is taller than Bill, Jim cannot be shortest. By using the same line of reasoning Jane cannot be shortest since Kathy is shorter than Jane. And since Bill is taller than Jane he cannot be the shortest. Therefore that only leaves Kathy to be the shortest. Then, since Bill is taller than Jane and and Jim is taller than Bill, Jim has to be the tallest. With one line of reasoning I was ruling out possibilities to come to my conclusion and with the second line of reasoning I was focusing in on possibilities to arrive at my conclusion. This example involved organizing and analyzing the information.

It does appear that learning to gather, organize and analyze facts better helps a person to become a better problem solver.

Communication skills allow an individual to send and receive information. The sending and receiving can take the forms of gestures, writing, speaking, reading and listening etc.. There are many ways in which development, injury or disease can affect one’s communication skills. The communication skills track of the NeuroPsychOnline system will present exercises that focus on some very specific areas of difficulty that we frequently observe with children and those with cognitive impairment. We will focus primarily on auditory discrimination, verbal comprehension, reading and following instructions.

Task 1 - Basic Attributes - As with all tasks you should review the Topics for Discussion list before starting this task and discuss points relevant to this session with your patient. Engaging in the same discussions over multiple sessions will be necessary for many of our patients.

Have your patient describe all the possible attributes of the objects as the array appears on the screen. If they do not fully understand, then start them out by pointing out that color is an attribute and that they should notice that the various objects are of same or different colors. Don’t go beyond that startup hint though. Have the patient think of the attributes themselves. If they get stuck then ask questions until they produce the correct observations. The ‘prime directive’ of our therapy is to train the patient to think for themselves, not to learn how to do these specific tasks. If you tell them how to do the tasks then you have removed the thinking from the therapy.

Task 1 - Simple Visual Reaction (Fixed Point) - As with all tasks you should review the Topics for Discussion list before starting this task and discuss points relevant to this session with your patient. Engaging in the same discussions over multiple sessions will be necessary for many of our patients.

This task can be completed in 12 clicks if a person responds quickly and consistently! Consistency is actually more important than speed. Ask your patient to stay relaxed and use only his/her finger to make the response. Watch that they don’t tense up their arm or body and get more of their body involved in responding than just the finger. They should keep their finger touching the mouse button at all times. Even though it is possible to finish in 12 clicks, up to 50 clicks are allowed. On the score screen you will see your patient’s reaction time reported in milliseconds. It takes 1000 milliseconds to equal 1 second. A score below 500 milliseconds is okay, below 400 milliseconds is good, below 300 milliseconds is awesome! But, if for some reason your patient cannot click that fast, they can still pass as long as they are consistently clicking at near the same reaction time. If a patient is actually pushing to their performance limit then consistency will come more easily. The statistical variance is used to infer consistency. A variance of zero would indicate perfect consistency. A average variance of less than 1200 (calculated on a moving analysis of the last five clicks), maintained over 4 consecutive responses is required for a pass.

Ask your patient to focus on the center of the screen. Even though the stimulus will present only at a fixed center point location, it is good to get your patient aware that they should be focusing on that point without any eye movement during the task. This will be important on later attention tasks (i.e. not moving the eyes) and will be easier to train at this point. Subtlely watch your patient’s eyes, from the side, to monitor for eye movement. If it is present remind your patient that they should not be moving their eyes.

If the feedback colors keep oscillating from good (i.e. yellow or green) to poor (i.e. orange or red) remind the patient that consistency and speed are required.

Visuospatial skills allow us to visually perceive objects and the spatial relationships among objects. These are the skills that enable us to recognize a square, triangle, cube or pyramid. They allow us to retrace our way across the city because we have a visual map in our memory from the last time we made the trip. They allow us to know that the car is closer to us and smaller than the building just behind the car. They enable us to realize that the car we see two blocks away is actually about the same size as the car that is just in front of us, even though it appears to be much smaller. Most of what we analyze visually would take many, many words to describe (remember the adage that a picture is worth a thousand words) yet we do it visually in a fraction of a second. Visuospatial skills include a wide variety of individual skills that vary from recognizing brightness/darkness, identifying complex intersecting angles and curves to recognizing faces from the shape of eyes, noses, mouths and hair. Impairment of these abilities can have a devastating effect on even simple daily functions that we take for granted. Imagine walking one block away from your home and not being able to find your way back! Fortunately, it appears that whether impairment to visuospatial skills was due to an accident or was present from birth, rehabilitative work in this area can greatly enhance functioning and thereby improve ones ability to function in daily life.

Memory refers to the ability to store, retain and recall information, events and procedures. Typically memory functioning is defined in terms of the length of time between the exposure and the recall (i.e. long term, short term and immediate memory). A more formal way of saying the same thing would be to refer to the three categories as remote, recent and working memory. Within these three general time based categories of memory there are further divisions of memory functioning. Visual (or non-verbal) memory refers to the ability to recall what one sees or experiences in terms of shape, size, location, position, color etc.. Verbal memory refers to the ability to recall information that is encoded in words and includes hearing, reading and any other avenue that involves speech and language. Procedural memory refers to the ability to recall how to do something. A person can have a weakness in one or a combination of these areas.

Working memory (or immediate recall) refers to the memory that we use at the very moment we are doing something such as working a math problem, looking up a phone number or just engaging in a conversation. Working memory requires joint effort from attention and executive skills. These three skills together form the constant “thinking” that we do to function from minute to minute. Information used in working memory is not necessarily stored for recall as recent or remote memory. Working memory information can be, mostly, discarded after a person finishes using it. There is a limit to the capacity of working memory. Research has consistently shown that an average person can hold about seven pieces of information in working memory, plus or minus about two pieces. So, the average person could hold about five to nine pieces of information in working memory for use in problem solving, dialing a phone number, working a math problem etc.. When working memory is reduced to a capacity of five or less items and/or when the ability to manipulate the information in working memory is compromised and/or when the ability to stay on track is impaired, then one would probably experience some difficulty in functioning in more complex and fast moving situations.

It appears that the capacity of working memory can be expanded by practice and by the use of compensation techniques. In addition, work to improve the attention and executive skills can improve the utilization of working memory. Accomplishing this can greatly improve a person’s functioning in daily life situations. If problems with more long term memory, such as recent memory (a few minutes to a few hours) and remote memory (longer than a few hours) are due in some part to low capacity working memory or impairment of attention and/or executive skills then practice and the learning of compensation skills can improve those memory functions as well.

The executive skills are so named as they oversee and manage the cognitive functions of the brain. They play a major role in information processing, abstract thinking, problem solving, initiation and inhibition. The executive skills organize, sequence, sort, group, relate, differentiate, combine, separate and many other operations with the data and information taken into the brain through the senses. The executive then uses this information to plan, reason, make decisions and initiate/inhibit responses. Cognitive flexibility is a desirable attribute of executive functioning as it leads to better information processing and hypothesis generation. Difficulty with initiation and inhibition is undesirable as it can interfere with responding or cause one to be impulsive and inappropriate in behavior. The executive skills interplay with the attention skills in determining the target of focus and keeping track during attention shifting and divided attention.

The attention skills of our brain allow us to focus on one part of what is going on around us while at the same time ignoring, to some degree, other things that are going on at the same time. Attention skills are necessary for us to be able to take information from our senses (like seeing and hearing) and transfer it into our brain for use in thinking, learning, problem solving and memory. We must be able to maintain attention long enough to get all the important information from the events upon which we are focusing. Attention span refers to how long we can maintain this focused attention. If a person has a short attention span then they might not be getting all of the important information.

Even though focusing is important we must, at the same time, be aware of other things going on, so if something more important than what we are focusing on starts to happen we can be aware of it and shift our focus over to the more important event. This is called attention shifting. Another example of attention shifting would be when we are tracking, for example, two things so that we spend a little time with one and then a little time with the other. Sometimes we must divide our attention and have some degree of focus on more than one thing at the same time. This is call divided attention or multiple simultaneous attention.

Sitting and watching for something to occur is referred to as vigilance. This is a process of maintaining our attention over a period of time while we wait for the something to happen. One way of sharpening our attention skills is to set up a vigilance situation and then train a person to respond quickly when the situation occurs. Feedback about whether the response was quick enough helps to train the person to attend better and respond quicker. Responding, by actually doing something like clicking a mouse button is called an initiation response. Sometimes, however, the best response to a situation would be an inhibitory response — which means responding by doing nothing. Impulsive people are poor at doing this. This type of exercise requires the cooperation of attention and executive skills as initiating and inhibiting are executive skills.

Our Track 1, Attention Skills is designed to provide training in all of these areas, one step at a time. In the beginning we work with focusing and initiation responses. We use the reaction time as a measure of these skills. Later in the series of tasks we start introducing situations that require a decision, initiate (make a response) or inhibit (don’t make a response), to sharpen the attention skills and train one to process information quickly but also accurately. Even later in the series, we introduce tasks that require attention shifting, divided and multiple simultaneous attention.

Once you have your own subscription, you can use NPO from anywhere in the world that you have access to an internet computer. This applies to professionals and to patients, students or any other end users. Just go to our website and login. The system will immediately recognize you, no matter what computer you used. However, you must have your own subscription, with username and password to do this. Any computer that you use does need an up-to-date Flash Player plugin installed. If it doesn’t then you can download and install it free from www.adobe.com or just click the link on our homepage.