Impaired awareness

Impaired awareness refers to the lack of ability to recognize deficits. Crosson et al. described a hierarchy of awareness levels that have implications for the level of intervention needed. Intellectual awareness refers to having a basic understanding. Emergent awareness refers to the ability to recognize a problem in real time. Anticipatory awareness refers to the ability to predict that a particular problem may occur in specific situations and settings.

Because impaired awareness can represent a safety risk, the minimum requirement is to modify the environment to reduce these risks. In the outpatient setting, impairments in emergent or anticipatory awareness are the most common awareness deficits. Milieu-oriented therapy is a way to address impaired awareness. Metacognitive strategies are those that improve one’s ability to self-monitor and alter cognitive functions. Cicerone et al. recommended the use of metacognitive strategies to improve executive functioning for patients after a traumatic brain injury (TBI) or stroke.

Attention

The most basic level of attention is focused attention, which is the ability to respond discretely to specific sensory stimuli. Sustained attention is the ability to maintain a consistent behavioral response during a continuous repetitive activity. A higher level of attention is selective attention, which is the ability to maintain cognitive or behavioral set in the face of competing or distracting stimuli. Alternating attention refers to the ability to shift focus between tasks that have different cognitive or behavioral requirements. This ability is also known as cognitive flexibility. The highest level on the attention hierarchy is divided attention. This refers to the ability to respond spontaneously to multiple task demands. A person who has impairments at one of the lower levels of attention will necessarily have impairment at all of the higher levels as well.

Cicerone et al. concluded that there is insufficient evidence to recommend direct attention training during acute and inpatient rehabilitation. However, they recommend direct attention training in the postacute period as a practice standard. Attention process training is a form of attention training in which patients complete a series of hierarchical computer tasks to improve attention. They also recommend supplementing direct attention training with training in compensatory (such as use of checklists or memory notebooks) and metacognitive strategies (such as self-monitoring, self-verbalization, and problem-solving) to improve generalization to real-world activities.

Memory

Typical manifestations of memory problems include difficulty keeping track of belongings and forgetting what, how, and when. Interventions targeting memory can be classified into two broad areas: restorative and compensatory. Restorative treatments are based on the concept that memory abilities can be restored through practice. They are not recommended in the TBI or stroke inpatient or outpatient settings because of their lack of effectiveness. Compensatory strategies can be classified as internal or external. Internal strategies rely on internal processes to learn and remember information. External memory strategies rely on cues outside of people to remind them of important information. Cicerone et al. recommended memory strategy training using either internal or external strategies for people with mild to moderate memory impairment. External memory strategies are the practice guidelines for people with severe memory impairment.

Emotional problems

Depression and anxiety disorders are the most common emotional problems experienced by rehabilitation populations. CBTs are based on the theory that thoughts, emotions, and behaviors are founded on an underlying belief system, and that emotional symptoms arise from negative, maladaptive, and underlying beliefs. Behavioral therapies focus on helping patients identify current patterns of coping, particularly how they may exacerbate emotional symptoms, and develop improved coping patterns and greater access to reinforcing and pleasant life events. The focus of supportive psychotherapy is on improving psychological functioning and reducing dysfunction in a positive therapeutic relationship. CBTs will likely be more effective for people with intact cognition, whereas supportive psychotherapy may be more appropriate for people with severe cognitive deficits.

Antecedent Management of Problem Behavior (eSlide 4.15)

Psychologists not only focus on treatments to reduce distress and dysfunction but also capitalize on opportunities to promote well-being and positive emotional adjustment following an injury.