Cognitive remediation is a teaching process that targets areas of neuropsychological functioning involved in learning and basic day-to-day functioning. This terminology can be confusing because some researchers use the phrase “cognitive remediation” to refer to environmental adjustments meant to ease cognitive requirements. In this article, the term refers to a treatment approach designed to address cognitive deficits through neural rehabilitation. This approach relies on the idea, demonstrated in many recent studies of humans and primates, that the brain can circumvent damage or loss through repetition of the same activity.
The goals of cognitive remediation are to bolster specific cognitive capacities that are weak. It is distinguished from a compensatory approach that seeks to get around a cognitive deficit by use of compensating strategies, such as using a notebook as a memory support in memory loss. Cognitive remediation has been applied in those who have had a traumatic brain injury (a stroke, tumor, or head injury), in those who have learning disabilities, and in people who have schizophrenia. For people with brain injury, remediation typically targets the following neuropsychological functions: attention and concentration, memory, planning, monitoring one’s work or behavior, and making adjustments based on feedback. Remediation is also used to help children and adults cope with learning disabilities. Learning disabilities can interfere with progress in reading; in understanding and communicating through spoken language; in writing; in arithmetic; in understanding such nonverbal information as telling time or understanding visual information; and in comprehending social interactions and cues. Difficulties with concentration, problem solving, organization, identifying errors, and using feedback effectively are also areas that can be treated with cognitive remediation. People with schizophrenia sometimes exhibit cognitive impairment, and cognitive remediation therapy has shown promise in addressing these losses.
Individuals who have had a traumatic brain injury will work with a remediator using computer programs that target one area at a time, such as attention. The individual is then helped to generalize what is learned from the program to real life. This intervention is usually done at a hospital, although it is not limited to clinical settings. Remediation for this group of people is considered helpful but not curative. It is typically practiced by a neuropsychologist.
Remediation for individuals with learning disabilities aims to bolster a particular area of learning or adaptation, such as in academics or socialization. Although the intervention varies according to the disability and the individual’s profile of strengths and weaknesses, the remediator will make use of the person’s stronger capacities to bolster the weaker ones. For example, the person might need help with written language because he frequently omits words from his sentences. Once it has been determined that the person’s oral language (both receptive and expressive) is adequate and that the motor aspect of writing is intact, the remediator has an idea of the person’s strengths and weaknesses in the area of writing. In this case, the remediator makes use of the person’s stronger auditory (hearing-related) skills to build up the capacity to translate spoken language into written (visual) language. Specifically, the remediator might read aloud a sentence written by the student (with omissions) and ask the student to identify the mistakes that he hears. The person identifies an omission that he hears and then is shown on paper the place where the word is missing. In this way, he can learn to identify errors visually that he can already identify through the auditory modality of listening. This particular exercise fosters visual awareness of errors, which is a symptom or outcome of the deeper problem of translating language from oral to visual form.
This process can also be achieved with computer-assisted tasks. These methods focus on gradually increasing the difficulty level and complexity of the cognitive functions being applied.
The process then continues with diminishing degrees of assistance. Specifically, after the student becomes more skillful in matching visual omissions with the auditory ones read by the remediator, the person himself begins to read the sentences aloud and identify the words that are missing from the sentences on the page. In the next step, he would begin to read his work silently with the same kind of scrutiny as in the previous exercise. In this manner, remediation fosters both learning and internalizing a cognitive capacity.
Cognitive remediation sessions for learning disabilities usually take place twice a week. This type of
Auditory —Pertaining to the sense of hearing.
Cognitive —Pertaining to the mental processes of memory, perception, judgment, and reasoning.
Compensatory —Counterbalancing or offsetting. A compensatory strategy is one that makes up for or balances a weakness in some area of functioning.
Modality —One of the primary forms of sensation, as vision, touch, or hearing.
Socialization —An ongoing process in which a person learns and internalizes the values and behavior patterns of his or her culture and social group.
intervention is practiced by psychologists, neuropsychologists, special educators, and learning specialists. The depth and breadth of the intervention will vary according to the remediator’s professional training and his or her particular area of expertise. Some professionals specialize in working with certain types of learning disabilities; some, like psychologists, may incorporate their understanding of emotional difficulties within their work as a cognitive remediator.
Cognitive remediation can also take a strategy-oriented approach, in which the patient practices tasks that require strategizing.
Before remediation can begin, the person being treated must receive a neuropsychological or in-depth psychological evaluation in order to identify the underlying neuropsychological capacities (i.e., language, memory, attention, visual perception, visual spatial abilities, motor abilities) that are interfering with acquiring the skills that are needed. The evaluation is also intended to rule out emotional difficulties as the primary cause of learning problems. Children with learning disabilities frequently experience feelings of inadequacy and low self-esteem that need to be addressed. If psychological difficulties, however, are the main reason for a person’s academic struggles, he or she should be treated with psychotherapy rather than cognitive remediation.
When remediation is targeting the problem area accurately, and the individual is actively engaging in the process, then progress should be evident in the skill area targeted, in the person’s awareness of his or her area of difficulty, and in his or her awareness of some techniques and strategies that are helpful.
See alsoLearning disorders.
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LDOnLine. A Web site addressing learning disabilities and ADHD. <www.ldonline.org>.
Susan Fine, Psy.D.
Emily Jane Willingham, PhD