Neuropsychonline Weblog

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.

Inconsistency in ability to focus and maintain focus is a hallmark sign of attention skill difficulties.

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 and variance (a measure of inconsistency) as measures of these skills. Later in the series of tasks we start introducing situations that require a decision, initiation (make a response) or inhibition (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.

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.

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.

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.

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.. Psychosocial skills must work together with our communication skills to enable us to understand that information, interact appropriately with other individuals and function within a socially meaningful context. Psychosocial skills allow us to interact with, perceive, influence and relate to others. Psychosocial skills include our ability to appropriately experience, display and perceive emotional states and relate these to the events and environments where they occur. If a person has trouble recognizing when another person is happy, irritated, angry, sad etc. or has trouble experencing these feelings then their interaction with others is likely to be poor and sometimes inappropriate.

There are many ways in which development, injury or disease can affect one’s communication and psychosocial skills. The communication skills track of the Neuropsychonline therapy system presents exercises that focus on some very specific areas of difficulty that we frequently observe with those with cognitive impairment.

We currently provide Clinical Reports for the WISC-III, WISC-IV and WAIS-III batteries for intellectual assessment. If you enter data you have collected from full examinations (ie you administered all the subtests and optional procedures) you will receive back a comprehensive, narrative report of about 15 pages written in a clear and informative manner making it most useful to you and to your referral sources for comprehensive diagnosis and treatment of your patients. Data tables and performance graphs are equally clear and understandable. However, if you elect to do only partial batteries you can still get a meaningful report, even if you only administered one subtest. All of our reports can be printed directly from the web page or copied and pasted into your word processor for editing by you. All reports now include weakness specific recommendations for remediation.

The VisionDx program is a quick differential diagnosis for localization of brain lesions based upon visual field defects. With data from a visual fields examination, the clinician can browse through the display panels to match up the results. The panel displays the possible lesion sites and indicates the vascular distribution that might be involved, when appropriate.

The AphasiaDx program is a quick differential diagnosis for aphasia that can be based on clinical observation and/or clinical testing. Upon responding to questions concerning the patient’s symptomology, the user is presented with the name and definition of the most likely aphasia syndrome along with an illustration showing the most likely areas of the brain that, when damaged, would produce the aphasia.

Our Headache Evaluation is the most comprehensive we have seen and it writes a report that can be utilized with little or no editing. In addition to organizing the evaluation data collected into a clear and precise report the program offers the top three “most probable diagnoses” given the symptoms provided. Ask of the patient specifically, or learn from your interview, the information required to answer as many of the questions in the form as possible. You can accomplish this while online (entering each response as you acquire the information) or you can print the form so as to facilitate your gathering of the information off-line. In either case, once you have the data, enter it into the form on-line and submit it. Within seconds to a minute you will receive a completed report, formatted and displayed as a printable webpage on your screen.

Example Headache Evaluation computer generated report:
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Headache Evaluation Report

October 17, 2009

Name : Jane Doe
Sex : female
Date of Birth : March/15/1980

Jane Doe is a 29 year old female who has experienced problems with headaches since she was 15 years old. Since that time the frequency of the headaches has increased and the severity of the headaches has increased. There is a history of headaches in this patient’s family.

The headaches do appear associated in time with this patient’s menstrual cycle. She does take birth control pills.

The patient reports that there are significant life/work stresses affecting her at this time. She indicates that she does not have an eating disorder. She thinks that she is both anxious and depressed.

The patient indicates that she has received treatment for her headaches in the past. She indicates that the following treatments have been effective:

relaxation therapy
massage
medication
time off work

This patient reports that her headaches occur about 1 to 3 times per week. Over the time period in which headaches have been a problem, there has been no observable time pattern to their occurance. The pain is described as usually coming on gradually, being moderate in degree and being such that it comes and goes. Typically, the headaches will last up to 24 hours from when the patient first notices them until they go away. She reports that her headaches tend to start during the morning after she has already gotten up from sleep. She reports that the headaches seem worse during the evenings. She indicates that the headaches seem to be made worse by:
drinking alcohol
smoking
excitement or crisis
after missing a meal or while dieting

She reports that the headaches seem to get better with rest.

The patient indicates that the headaches usually start following a stressful event.

When the headache first appears the pain is usually unilateral, more anterior, focused in one spot, around one eye and above the eyes. Later after the headache is fully developed the pain is usually bilateral, more anterior, more general in location and above the eyes. The patient reports that there is a tenderness associated with the headaches located in the neck area. The patient reports that the following medications have been of help in the past:

Analgesics
Narcotics

The patient checked the following attributes as applying to her headache:

throbbing
a pressure inside the head
worse when straining like to go to the bathroom
worse while standing up
aching neck, shoulders or back
trouble falling asleep
tenseness
anxiety
irritability

Diagnostic Considerations:

The pattern of signs and symptoms endorsed by this patient appear most like the following headache types ranked in order of probability:

Tension Related Chronic Mild Migraine
Occipital-Orbital Migraine
Tension Headache

Note: This program and report is intended to serve as an aid to a competent and licensed clinician who is solely and totally responsible for evaluating the patient and making a diagnosis based upon that clinician’s expertise and opinion.

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