Psychological Software Services

CART - Lesson 1:

Attention Skills - The Basics

      Any therapist conducting any kind of therapy must have a theoretical basis upon which the activities of the therapy are based. Cognitive functioning and rehabilitation are complex and require an indepth understanding by the therapist of normal and impaired brain functioning. In addition, the therapist must have knowledge of and clinical insight into the areas of personality, psychological state (i.e., depression, anxiety, psychosis, neurosis, paranoia, etc.), psychological mechanisms (i.e., reaction adjustment and coping behaviors) and human interaction. Without sufficient background in physiology and anatomy, the therapist would not know if eye movements or vision were affected or impaired. They would not know, for instance, that auditory information can be processed faster than visual information and therefore they should expect a patient to respond to a sound stimulus more quickly than they would to a visual stimulus. If, indeed, this is not the case for a particular patient, then the patient may have impairment of sensory, attention or information processing mechanisms within the auditory system. Points like this may seem trivial, but this one example could be a vital diagnostic piece of information and one possible explanation for why a child no longer seems to be able to follow verbal instructions in school. As we proceed with these LESSONS, I will include in the articles many of these physiological and psychological signs and symptoms. You will see that every therapy session is a very interactive and investigative process.

      The skills of thinking, behaving and otherwise functioning developed over a long period of our growing up and maturing. Our more developed and proficient skills became that way because of inherited potential in those areas and because of the demands and experiences we faced as we grew up. Simply put, skills develop in reaction to demands placed upon the person and from that person's experiences in living. Why should it be any different when we, as therapists, step in to help the impaired person develop and strengthen skills. Just telling a patient how they should function or how to do a daily task will not usually result in that patient's acquiral of the skill. To really accomplish rehabilitation we would not want to just go around teaching household or personal living tasks, though we certainly would want to do this if it were needed. Cognitive rehabilitation should enable the person to think for themselves and to do this thinking at the highest level for which they have potential. The only way to train, retrain and/or develop these skills is by placing demands on the person that require them to utilize the skills. The person must experience and overcome the demands a sufficient number of times so that the skill becomes a part of the person's way of functioning.

It is my opinion that an individual must be able to take in information properly, in a timely fashion and accurately in order for any, so called, higher mental functions to work properly. We cannot expect our patients to learn, reason, make good decisions, respond and behave appropriately and to function at their optimal potential if brain mechanisms are distorting information or hampering the receival of it. I often hear therapists say that in their opinion the patient's attention skills were good so they did not see a need in wasting therapy time at this level. I also often hear others say that their patients were too intelligent to need work at the level of the attention skills. I cannot say that I have ever met a patient with a brain anomaly (i.e., injury, stroke, tumor, encephalitis, etc.) who showed fully intact attention skills. As a therapist and diagnostician you just need to know what to look for to see the problems. A thorough neuropsychological examination can be extremely helpful in demonstrating the presence and nature of those very basic problems. I am not talking about short form or screening battery examinations. My toes curl up when I hear clinicians say they don't have the time or want to take time to do a whole examination, that examinations don't provide useful information or that they can get all the information they need from one or two subtests from the WAIS-R. If I am ever head injured, I certainly hope that I get treated by people who will pursue every avenue of investigation and treatment to its fullest extent. Our patients and their families should expect, and they deserve, no less.

We start all of our patients in therapy working on simple visual and auditory attention skills. If problems are slight or if they don't exist in a particular area, then the patient will advance right on through the exercise with no difficulty. If problems are greater, then we must take the time to retrain these basic skills before pursuing higher level more complex skills that depend heavily upon the more basic skills. Retraining at basic levels is not a glamorous affair. It is not fun and games time for the patient. In conducting cognitive rehabilitation therapy, we are not trying to entertain our patients. There are very specific skills being addressed by the therapy tasks. If we are attempting to develop or strengthen attention, we must make sure that the effort to attend is actually required of the patient. If we choose tasks that magnetically draw their attention because the tasks are lively, graphically fascinating, or otherwise captivating, then we will not accomplish our goals even though by all appearances from watching the patient do the task, it might seem so. I sometimes hear patients and often hear therapists say that some of the basic attention tasks are boring and so they choose to go ahead and work with memory or higher level problem solving. So what if a task is boring!

The very quality that it may be boring, actually would make it more therapeutic for the patient. If the patient can maintain and focus attention well enough to meet criterion when the task is not so exciting, then I feel more assured that those skills have actually been reacquired or strengthened. As for the therapists, if they are closely observing eye and hand movements, searching to discover sources of inconsistency in performance, or engaging in clinical observational analysis along many other lines, then they would have no time to be bored.
So let's get into the first few therapy sessions with our patient who has experienced some type of brain impairment. We are going to start by working with visual and auditory attention skills. We will also introduce some exercises that are more demanding in terms of visuomotor skills, but which will allow additional practice with attention skills, help with speed of thinking and start to provide more dynamic response/feedback situations that will strengthen the patients self monitoring and self correcting skills. By dynamic, I mean that there is continuous movement on the part of the stimulus and/or a requirement of continuous movement response from the patient.

Visual Attention

The first visual attention skill task is program one from Foundations I, entitled Simple Visual Reaction. This exercise presents a one inch yellow square (which is modifiable) on a black screen. The time delay between presentations is randomly determined so that the patient is not able to respond automatically on rhythm and the delay varies from about 1 second to 4 seconds. The patient is required to observe the screen and to press the response button as quickly as possible whenever the yellow square appears. There are two positive feedback stimuli and one negative. For a correct response, the yellow square is erased from the screen and the computer makes a Ta Da sound. If the button is pressed when there is no stimulus, then the computer makes a chord sound.

There is much more to this task than just obtaining a visual reaction time from the patient. The observation and assessment of certain basic visual skills is an extremely important aspect of the clinical activity of the therapist during this task. It is critical that the patient adheres to certain rules when doing this program so that the therapist can make some diagnostic decisions that could lead to a compensation rather than a retraining strategy in the specific area of visual skills. With some patients we may already know from the initial examination that visual impairment exists, however with many, the problems may be so slight or so far removed from the skills the examination assessed that they are not already identified.

When most nonimpaired people are asked to do the Simple Visual Reaction task they will, without being told, focus their vision at center screen and then do the entire task without moving their focus. This means they are attending to the whole visual field simultaneously, not just to central vision. Nearly all of our patients approach this task by constantly moving their eyes about the screen. Whenever they see a yellow square they shift central vision to the square and then press the button. One big problem here is that if the person can only process and respond to what is in central vision, then they will be handicapped in every visual situation they encounter. It may be that the handicap is only one of being slowed down, but in many situations, being slowed down in processing visual information means being left behind and/or overwhelmed sometimes to the extent that it is difficult for those with this brain injury related problem to understand the events that are going on around them. So, in therapy, what we want to do is, first look at how the patient is utilizing their vision based upon their own strategy. Then, if they are not keeping their vision focused center screen, the therapist should discuss with the patient what they are currently doing and try to draw from the patient the more appropriate strategy. A rule of thumb must be interjected here. If you can get the patient to generate the appropriate strategy from their own thoughts rather than from you just telling them, you will find they will have a much easier time incorporating the appropriate strategy within the program and in their daily functioning.

A second reason for having the patient focus their central vision and utilize their full visual field, is to aid in further determining if they are receiving and processing visual information equally well from all areas within the field. Usually, visual field cuts or defects will be detected upon initial examination, but they are not always. More subtle field neglect problems can escape detection until the patient is placed in the more precise situation of having visual reaction times assessed. We use the program Visual Reaction Differential Response as a part of our neuropsychological examination so that we get visual field reaction times separately for the four quadrants before we start therapy. For most of our own patients then, we know of the existence of visual field problems before we find ourselves doing the Simple Visual Reaction program with them. When visual field problems are present, our strategy in therapy will differ depending upon the problems.
For situations in which the patient is experiencing an actual field cut (i.e., hemianopsia, quadrantanopsia, etc.) we will want to accomplish several goals in therapy:

Clearly this would be classified as training compensation skills, as no matter how hard we work in therapy, we cannot restore the vision loss. When we are sure that the problem is one of vision loss and not severe neglect, we begin to move the central focus point toward the side of the computer screen that is not being seen. We have the patient mostly accomplish this by moving their eyes over, but to a lesser degree they should keep the head turned slightly toward that direction as well. A small sticker dot placed on the screen can help in determining the best focus point and then help to establish that point as a habit during the initial stages. When performance has sufficiently improved so that reactions are consistent and quick from all areas of the screen, then the use of the dot should be faded so that the patient is operating without aids. It appears to be helpful to daily general functioning for people with field cuts to get into the habit of intentionally looking to the area of the defect on a frequent and regular basis. This, too, can become very automatic with much practice. On the computerized tasks, we establish the focus point as already described and then have the patient scan from there to as far toward the defect side as is necessary for them to see the whole field and then move focus back to the resting focus point. We may have to issue reminders initially for them to maintain this pattern, or at least to get them to initiate it. After the technique becomes more habitual and automatic, the reminders can be faded.

When the problem is one of neglect, we will want to attempt a retraining strategy first. In all but perhaps the most severe cases of neglect, we have been able to retrain attention to the neglected field. With these patients the focus point must be kept at center screen. If they initially need help with this, the sticker dot can be used and then faded. The patient may need frequent reminders that they concentrate hard on the neglected field without moving their eyes. With some patients just having them talk aloud, reminding themselves of this, has been sufficient.
We have found that all patients doing this task, with or without field impairment, can experience great difficulty in refraining from moving their eyes. The therapist must be positioned so that the patient's eyes are clearly visible to them and they should inconspicuously watch the eyes as the task is being done. Feedback should be provided to let the patient know when their focus is appropriate to the therapist's prescription.

The manner in which the patients make their button pushing responses is important. The mouse, on which the response button is located, must be placed solidly on the table in front of the patient and centered in respect to the computer screen. Unless it is physically or anatomically impossible, the patient should be required to use the index finger to make responses. The hand should be resting so that the response is made with the finger and not with the arm. The criterion scores printed in our manuals were determined using these procedures. Any deviation away from this format will invalidate comparisons of the patient's performances to the criterion levels. You must control the manner with which responses are made and by which the task is presented for this and all therapy exercises. Do otherwise, and comparison of the performance levels and determination of change from one session to the next is simply not valid.

Fifteen visual presentations are made during Simple Visual Reaction that require an active response from the patient. This stretches the concentration span demands to a little over one minute, which is really not a very long period. At least that number of presentations are required for the statistics to be meaningful. Two of the statistics reported upon completion of the program are of primary importance. These are the average reaction time and the variance. The reaction time provides you with a measure of how quickly the person was able to see, perceive and process the sensory information about the appearance of the stimulus, and also of how quickly the person could put together and execute the motor response. Very fast reaction times would indicate that the person was performing well in the sensory input information processing, and motor response phases of their performance. However, reaction times can be slow because of problems in any one or a combination of these three areas of functioning. Observation by the therapist of the patient doing the task can often help determine where the breakdown is occurring. Sometimes it is necessary to observe on several different tasks in order to track down the specific problem. For example, comparison of performance levels on the visual and the auditory reaction time tasks can provide information that may help to determine if a visual attention or processing problem is the etiology of poor performance scores. If the person can perform well on the auditory task, but not on the visual task, then the problem would lie within the visual sensory and attention systems since the motor demands of both tasks are identical.

The variance is a statistic that can help in tracking down problems and can also help in determining when a patient is ready to move to the next steps in therapy. Variance is a measure of consistency in the scores. The more closely grouped the scores, the lower the variance will be. If every response was made with exactly the same reaction time, the variance would approach zero, indicating perfect consistency. With this knowledge about the variance in mind, the therapist can look at the reaction time and draw further conclusions about the patient's capabilities. If the reaction time is fast but the variance is large, one might deduce that most of the patient's responses were quick, but that there were one or more times when attention lapsed, the patient was distracted or something occurred that interfered with the patient's otherwise very good responding. If the reaction time is slow and the variance is large, it is likely that sensory input problems, visual problems, or problems with maintaining focus are at fault. When reaction times are slow but variance is fairly low, then some consistency in response is suggested. Often, in these cases, there is a motor problem that is slowing down the response and that motor problem has about an equal effect on every trial, therefore the low variance. When, a therapist, you are convinced that this last case applies to your patient and if you do not expect improvement with the motor problem, you may need to relax the goal criteria when making your decisions as to when to go on to the next level. At some point later in the therapy, exercises will increase in the cognitive demands so that it will take enough time just in thinking aspects of the task, that this motor based inflation of responses will no longer be a problem.

Ideally then, for Simple Visual Reaction, we are looking for the fastest possible reaction times, low variance and performance characterized by no eye movement. With our patients, these goals may accomplished for this one task in anywhere from one to five weeks. Moving on before these goals are accomplished simply makes no sense. Tasks are only going to get more difficult from here and problems with skills left untrained or uncompensated for are going to snowball. In addition, this should be accomplished for each hand individually, even if one hand is paretic or spastic. I am frequently amazed at the amount of return of functioning we see in a paretic limb one to two years post injury, well after other therapies have stopped, when all we are doing motorically is demanding that the patient use the paretic limb to perform the computer exercise in addition to the nonparetic limb.

Auditory Attention

Now let's move on to Simple Auditory Reaction. This task is basically the same as Simple Visual Reaction except that the target stimulus is a sound rather than a sight experience. In order to be able to make comparisons between the performances on the two programs, all conditions must be as identical as possible except for the target stimulus. Therefore, the patient must sit exactly as before, focusing vision at the center of the screen. The mouse must be on the table, centered relative to the monitor and the patient must use the index finger to make the response.

All information about the statistics for Simple Visual Reaction apply similarly to Simple Auditory Reaction. We are looking, ideally, for fast reaction times and low variances. The reaction time for the auditory experience should be about .05 seconds faster than that for the visual experience. As stated earlier, motor impairment can interfere with interpretation of the results on these simple reaction time programs and must be accounted for when present.

While engaged in either of these two exercises, the patient should try to keep a blank mind, broaden their sensory intake, raise their level of arousal from within and respond without specifically thinking about making the response. They should be on the edge of their seat, highly alert and poised to strike!

Mazes

Usually we also assign Mazes, from Visuospatial I, during the first session of therapy. This task provides a set maze pathway (it is the same path each time) that has a generous amount of movement space between the walls. The object is for the patient to move the square pawn through the maze to the end as rapidly as possible with as few wall bumps as possible. The visuomotor demands of the task are easy to see, but there is more therapeutic value in this task than just that. The task provides a dynamic feedback situation in which every move made by the patient is instantly seen in the movement of the pawn and every wall bump sets off a beeping sound. So a primary aspect of this task, is to exercise and strengthen the self monitoring response adjustment systems. Typically we see more than a little frustration from the patient as we push for them to become more proficient and faster as they practice the task. Frequently, this necessitates a pause in doing the task to talk about how frustration is being experienced and witnessed, about how this same kind of reaction is being displayed in everyday life and about how to adjust to and handle frustration better. These little excursions into counseling types of activities for this and other psychological/emotional difficulties are a vital part of cognitive rehabilitation therapy and with most patients, will occur frequently.
Typically people will start out to do the Simple Maze task by moving only on horizontal and vertical planes. The best performance can be gotten by also moving diagonally whenever appropriate and possible. Discussion with the patient, in which the patient is asked to come up with additional movement strategies will usually bring out of the patient this diagonal strategy. Not only is this an advance in the visuomotor aspects of the task, but also in the person's more openminded and more flexible thinking.

Getting Experience with the Therapy Tasks

Experience with doing the tasks is what results in the development of the attentional, visuomotor and psychological skills being addressed. Several therapy practice sessions of about 45 to 60 minutes each, spaced over the day, appears to be adequate for producing change in an acceptable amount of time. Our patients may spend one or more weeks fully mastering the programs detailed in LESSON 1. The next set of programs, to be presented in LESSON 2 will be more complex versions of what was presented here. Until this level is mastered, it makes no sense to go on to more complex levels.
Expanding the therapy session to incorporate and correlate daily living problems with problems witnessed in the therapy session serves to make the exercise more meaningful, and to help to generalize the skills acquired in therapy for use in real life.

  CART - Lesson 2

More Attention and Executive Skills

As we ended Lesson 1, we had our patient working on Simple Visual Reaction, Simple Auditory Reaction and Simple Maze. As performance on these tasks progresses, we should see the patient utilizing the full visual field, maintaining focus for a longer period of time and being better able to profit from feedback. For further refinement of these skills, we typically introduce Simple Visual Reaction with a smaller square and Complex Maze once the patient is showing consistency and speed on the level 1 programs. In many cases we will have had opportunities to deal with frustration and other more psychological issues such as lack of self confidence, as the patient works on these initial programs. If the patient and family are motivated and really taking the therapy seriously, a routine will have been established at home within which the patient is devoting several hours of diligent work each day to the exercises. In addition to the direct benefits to the enhancement of cognitive skills, the patient will be exercising discipline over themselves to accomplish this. This work demand will also help with increasing physical and mental endurance and, in effect, will serve as an informal work hardening experience. As the patient begins to experience some success in achieving therapy goals, self confidence should begin to build. The therapist should closely monitor these psychological factors and appropriately discuss and reinforce development in these areas.

  So far, our tasks have required the patient to monitor the screen and initiate a response when certain set conditions were presented. In doing this repeatedly, we will have established a specific "mental/motor response set" in the mind of the patient. Basically the response set to this point has been, "when I either see or hear a stimulus, I immediately push the button as quickly as possible". The only inhibitory type of behavior we have required so far is to ask the patient to wait for a stimulus to appear. Occasionally a patient or student comes along who will exhibit a problem with even this simple inhibition demand and they will commit an error of responding when no stimulus is present (i.e., commission error). With most of those who show this problem, simply making them more aware of the behavior will be enough to help them control their responses. With a few people, we have had them keep their finger away from the button until after the stimulus is presented. We then gradually move the finger closer to the button over several runs of the program until we can finally let them keep their finger on the button continuously without them making the error response. This impulse control problem or lack of inhibitory will-power has to be dealt with here, because the next step in therapy will increase the temptation, so to speak, for making a poorly inhibited commission error.

  You should be seeing now that at each point of therapy, we are working directly on several cognitive skills and that these skills are the primary focus at each of these points. However, I hope you can see also that we are creating conditions such as the mental response set that will become important in therapy at later points or steps. You will see clear examples of this notion of "setting the patient up" as we get into Lesson 2. I must note here that even if a patient or student can meet criterion on the Lesson 1 tasks the very first time they do the tasks, you must still assign practice on the tasks in order to accomplish "setting the patient up" for the next series of exercises. Even if they are doing so well from the beginning, they should be able to improve even more on their speed and consistency.

Assuming that criterion have been met for Lesson 1 tasks, we will make a change in the patient's therapy prescription. A sequence of tasks from Foundations I replaces the simple reaction tasks. The sequence is extremely important and any deviation from the sequence will entirely change the nature of what we are trying to accomplish here. The programs to be used and the order of presentation are as follows:

The patient or student should repeat this sequence several times with the right hand and then with the left hand during each practice session. Th sequence first asks that a response be made to a specific stimulus and then on the very next task, the patient or student must inhibit to the appearance of the same stimulus to which they were just responding. We have seen patients try to ignore the visual prestimulus by closing their eyes or by looking away from the screen. The eyes must be kept focused on center screen throughout the entire sequence. The patient should progress to the point to where he/she is able to match or better their response times and consistency measures (variances) from the Lesson 1 tasks. They must progress to the point at which they are not making any commission errors. Typically this sequence can be mastered in one to two weeks of practice sessions.

The next sequence of tasks further stresses the inhibitory behaviors and also requires that a stimulus discrimination be made. The response to be made (i.e., one of initiation or one of inhibition) is determined by the discrimination of the stimulus presented. The whole sequence of the tasks included is as follows:

  When the patient is properly "set up" from the previous therapy exercises, he/she will initially experience difficulty inhibiting him/herself from making a response to the appearance of the blue block or the nontarget tone. Make sure the patient is focusing on the center of the screen and that the finger is poised on the mouse button so that the full benefits and intentions of this sequence can be realized.
Typically the visual choice is easier to make than the auditory choice. With some patients who show difficulty making the auditory choice, we will introduce only the visual part of the sequence during the first few sessions. With some patients, the whole idea of one of the response choices being to do nothing is difficult to grasp at first.

The patients who exhibit the most trouble with this sequence also tend to be the people who are getting into problem situations due to impulsive behavior or loss of inhibition in their daily lives. These daily living problems range from situations in which the patient says too much of the wrong things at the wrong times causing hard feelings or embarrassment, to situations of sexually acting out, getting involved with drugs or, in one case, running up a $10,000 tab in telephone calls to 900 sex numbers.

  I recall one young female patient, a registered nurse, who having experienced a rather severe multi-embolic stroke ended up in therapy with us some three years later. She had had a strained relationship with her mother prior to the stroke but afterwards her power of inhibition and impulse control was so poor, it was like a war zone any time these two came together. When we began working on this sequence of programs she just absolutely could not refrain from pushing the button on the blue block stimulus. We resorted to holding her hand flat on the table until she could verbalize what her response was going to be and then I would release her hand. Even with these measures she would occasionally proceed to press the button after I released her hand, even though she had correctly verbalized that she should not press it. Eventually over a period of weeks, she got to the place where she could keep her finger continuously on the button without making errors and with very respectable reaction times. About the time she was able to accomplish this she came into therapy and stated that during the past week it had truly dawned on her what we were trying to accomplish with the blue block program. She said she had been visited by her mother and that as usual, it was only a matter of a few minutes before her mother said something that infuriated her. Just before she blew up at her mother, she stated that she started to say "blue block, blue block" silently to herself and was able to contain herself from getting into an argument. We do not always get such blatant examples of the effectiveness of what we do in therapy, but it is greatly rewarding to us and the patient when we do.

Any time you as the therapist can draw a concrete picture of the relationship between what is being addressed in therapy and what is happening in real life, the therapy will be greatly enriched by your doing so. We are not just trying to teach someone to run a computer program. Always keep in mind the cognitive and life skills being addressed and discuss these reflections in depth with the patient. With our young student patients who were referred because of attention deficit problems, these sequences of programs are extremely important for helping them acquire impulse control, better discriminatory powers, and more accurate responses.

Lack of flexibility in thinking and self centeredness are characteristics we often see, particularly with our head injured patients. The sequence of programs I will present next were designed to work directly on the rehabilitation of perceptual motor problems and visual orientation and generally on thinking style and flexibility. As with most of the tasks, these exercises provide an avenue for dealing with social and psychological issues as well as provide an opportunity where the therapist can digress specifically into areas of being able to see someone else's viewpoint, being open minded and being able to exhibit flexibility in thinking.

This sequence actually involves a single program, Cube-In-A-Box from the Visuospatial I package. The task is initially presented as an eye hand coordination and visual perception training exercise. The program presents a large square on the screen that is moved randomly about the screen by the computer. A smaller square block is also present on the screen, but its movement is under the control of the patient via the manipulation of the mouse. The task for the patient is to keep the small block within the boundaries of the large square. Since the large square is constantly being repositioned by the computer, the patient has to be constantly readjusting the position of the small square. The score is based upon the length of time the patient is able to maintain the position of the block within the larger square. The higher the score, the better the performance. This is practiced with each hand, if possible, as with all of the tasks so far. The patient must practice this task until the criterion score can be fairly easily attained on each and every trial. Even if the patient shows skill on this task when it is first presented, the therapist should reward the performance and skill, but ask that the patient attempt to improve on the performance during practice sessions for the one week period. As you might expect by now, this is to set the patient up for what is coming next. The response mind set in this case is simply the association that moving the mouse in certain directions results in a movement of the block on the screen in the same directions.

Now, supposing the patient has mastered the task as already assigned, the prescription is changed so that the task is to be performed in the following manner and sequence:

In effect, steps two and four make all visual perception and actual movement totally reversed. With the reversal of the mouse left becomes right, right becomes left, up becomes down and down becomes up. Flexibility in thinking and being able to view from a different perspective definitely become factors in performing well on the sequence. At first, many patients show extreme frustration and may voice that it is not possible to score the same for all orientations. Utilize these opportunities for counseling about dealing with frustration, having self confidence, building motivation and exhibiting determination. It may take time and much practice for some to master this sequence, but the results in terms of skills and psychological boosters are well worth the time and effort. For those having a particularly difficult time with this sequence, there are aids that the therapist can employ at first and then fade away. One effective aid is to stand behind the patient with your hands placed on the patient's shoulders. Gently push the patient's body in the direction that the mouse must be moved to accomplish the task and have the patient utilize the cues provided from this to more correctly move the mouse.

There is something I have not stressed to the therapist yet that is made obvious by what I have just said. You, the therapist, must be accomplished at each and every task before you ever sit down to do any task with the patient. That means you have to practice and master the tasks yourself before you use them with a patient. Whenever we hire a new therapist, they must go through a training period that includes mastering the therapy tasks before I will let them see a patient. I received a telephone call from an irate therapist who was angry that earlier versions of my software did not have complete instructions on the screen prior to the task. She had gone into a session to work with a patient and was embarrassed because she could not find instructions on the screen and was unable to do the task with the patient. My response was that I felt it to be highly unethical that she could be doing so-called therapy and charging for it when she did not even bother to know her therapy exercise before attempting to use it with a patient. How could she have possibly have had a treatment plan if she knew that little about the very task she was calling treatment.

With this particular sequence, it is important to switch to the next program after every run and not just practice on a single orientation. Sometimes a patient, even though instructed not to, will go home and practice only on the reverse orientation since that is the most difficult on which to score well. This is usually fairly obvious at the next therapy session as the patient has actually established their own mental response set that causes them then to perform poorly for the normal mouse orientation. For hemiplegic patients the sequence, of necessity, becomes one of reversing back and forth with the same hand. With those with hemiparesis, we may need to accept slightly poorer performance from the affected side depending upon the nature and severity of the paresis.

The tasks presented in this lesson actually cover a lot of ground and typically take our patients from three to six weeks to master. This is with two to three hours of daily practice over that time period. In many cases the counseling needs are greater than can be handled by a therapist not trained and qualified for in depth counseling. In these situations working in conjunction with a psychologist or other counselor is very necessary.

  CART - Lesson 3

Visual Attention - Field Neglect and Anopsia

In Lesson 3 we will introduce a program that is slightly more complex and demanding than those of Lesson 2 in terms of the stimulus situation presented to the patient and the responses required of the patient. Tasks up until now in which a reaction time was measured required the same response (i.e., a button push) to any and every stimulus appearance (i.e., yellow block or sound) on the most basic level. On the second level, the patient or student had to make a stimulus discrimination (i.e., color of block or pitch of sound), but the response was still the same for all trials when it was proper to make a response. With the introduction of Visual Reaction Differential Response (VRDR) from Foundations 1, in this lesson the user is required to analyze more information from the display screen and choose from two possible movements when making the response. Because of the extra information processing demands, the user's reaction times will be .2 to .3 of a second slower than before.

The screen display from this program shows a solid colored screen divided in half by a vertical line. The user stares intently at the center of the screen as he/she watches for the appearance of a small dark block that can appear anywhere on the screen to the left or right of the vertical line. The proper response is for the patient to quickly push the mouse button on the same side (i.e., left or right) as the block appears on the display screen. The accuracy of the response and the reaction time are recorded by the computer. While the display screen is presented as being divided into equal halves, the computer actually monitors the screen as though the display were divided into four equal quarters. The location and time of presentation of the stimulus block is randomly determined, but the program does insure that nine trials are presented in each of the four quadrants. Upon completion of the exercise the program also reports separately, the average reaction times to the stimulus blocks presented in each quadrant. If the patient kept their eyes focused on the center of the screen throughout the task, then not only does this task serve as the next step in our visual attention series of exercises, but it serves as an excellent measure of visual field neglect or visual field defect (i.e., anopsia). A small yellow square is placed center screen to provide a focus point.

Let's talk about the visual field testing aspect of this task for a moment. Many of our patients do experience visual field problems and many of these problems have gone undetected before the patient started working on the computerized therapy with us. The more gross visual confrontation screening examinations done by neurologists, neuropsychologists, occupational therapists and others of us doing examinations just cannot pick up on subtle problems like the computer can. In most cases we all discover the field defects or field cuts in which there is actual loss of vision, but even with these cases, I have seen patients especially with upper quadrant quarter field cuts that were not previously documented. This problem is blatantly apparent when the patient sits and sits with no response while there is a stimulus block present on the screen in one corner, yet the same patient responds very quickly when the block is anywhere else on the screen. The field neglects can range from very subtle to more blatant. The sign of a neglect problem is that responses to one or two quadrants are consistently and noticeably slower than those to the other quadrants.

  In one very memorable case, we were seeing an eleven year old girl who had experienced a head injury in an automobile accident. We had been seeing her in therapy for a couple of months when her school teacher called to discuss the difficulty the child was having in returning to her studies. From our therapy work, we were aware that the child was experiencing a pronounced left field neglect. Upon visiting the school, the first thing we noted was that the child's desk was on the far right side of the classroom so that most of what was happening in class was in the visual field that she neglected. There were a number of other observations and recommendations that came from our visit, but I feel that moving the child to the left side of the room and making the teacher aware of some of these "invisible" problems did more than anything to help this child.

The environmental manipulations in this example case served to help with the immediate problem, but our goal in therapy was to eradicate the problem. We have learned over the years in working with dozens of brain compromised people experiencing visual problems, that proper therapy can greatly improve or eradicate many of the visual problems we encounter. While there is nothing to be done for an actual field cut except to train compensation skills, we have had great success in retraining visual attention to areas of visual neglect. The degree of success does appear correlated with the severity of the neglect and in some of the more severe visual neglect cases, we have ended up also teaching compensation skills.

  For those without visual field problems then, VRDR is an extension of the visual attention training already started in Lessons 1 and 2. The analysis is more complex and the response requirements are more complex. For those with visual field problems, the exercise is much more. When working with a person who is experiencing a neglect, we keep the visual focus at center screen and frequently use the yellow focus point or a sticker dot as an aid. As the task is proceeding, the therapist constantly reminds the patient to look at the neglected side, but without moving the eyes or changing focus from the yellow focus point or the sticker dot. The therapist must closely watch the patient's eyes to make sure they are not moving. Once some success is apparent with this strategy, then the therapist has the patient verbally (aloud) remind themselves to "look" at the neglected side, once again without actually moving their eyes. With success the self reminders change to silent reminders. By the time goals are accomplished for all four quadrants, the patient should be automatically and subconsciously maintaining awareness of and attention to the previously neglected side.

  Those with visual field cuts are treated differently. First we want to move "resting" focus more toward the side of the field cut and increase awareness to the peripheral vision in the good visual field. This, in effect, moves more of what's in front of the patient into useable vision. Secondly, rather than just having a focus point or a resting eye position, the person must develop the habit of regularly looking toward the side of the field cut. We attempt to build these skills and habits in therapy by requiring the skills during the task, again with VRDR as the starting place. With this patient we move the sticker dot toward the side of the cut a little at a time until we feel from the scores that we have found the optimum point. Then we have the patient move their eyes from the dot, to the side of the screen and back, in a regular pattern. Allowing the patient to hold their head slightly turned toward the field cut is fine, and in fact when you observe them doing this away from therapy, it is a good sign that compensation is becoming more automatic.

  CART - Lesson 4

Expanding on the Attention Training

In Lesson 4, several programs will be introduced that will further enhance some of the skills that we have already begun to address. The complexity of the presentation, the analysis required by the patient and the responses demanded of the patient will be increased in this series. As always, moving to this lesson requires that the patient has mastered the work of the previous lessons.

  The first program I will present is a program from Foundations I entitled, Visual Discrimination Differential Response (VDDR). The task is a simple evaluation of the visual reaction time tasks on which we have already been working, except that on this task the patient is presented with two stimuli; each of which require a different response. The patient has to make a visual discrimination on the stimulus side and then make a response differentiation on the response side. The stimulus discrimination involves making the detection as to whether the square presented on the screen is blue or red in color. The response differentiation involves a decision as to whether a right side or a left side button push should be made. The patient sits, as on earlier tasks, staring at center screen with the left and right hand poised on the response keys. We start out by assigning the red square to a left button press and the blue square to the right. Whenever the red block appears the patient must press the left button and when the blue appears the right button is pressed. I came upon using and assigning the red color to the left button when I discovered with some of my early patients that there was a very strong tendency for them to associate the "R" words and make a right button response automatically to the red block. This set up then, with the red assigned to the left button, maximizes the concentration and inhibition skills needed to appropriately perform the task. That the task follows the planned hierarchy of making each new task slightly more complex and demanding, is fairly obvious from the reaction time scores. It typically takes from 100 to 150 milliseconds more time to perform this task than seen with the same person on tasks involving the simple one response visual and auditory discriminations. Once a person has mastered this task so that criterion can be consistently achieved, we go a step further that demands even more from the patient in terms of their having to reorient their thinking and show flexibility. We ask the patient to reassign buttons to colors in the modify screen so that on alternate runs of the program, opposite responses are made to the colors. That is to say that red is reassigned to the right button, and blue to the left button. Having firmly established by this time that a red square requires a left button response, the demands on the patient to reorient, resist perseverating the old response and demonstrate flexibility, is greatly enhanced. The demands of doing this switching routine by this method in which we intentionally and firmly establish a certain stimulus response set prior to starting the switching, turns out to be much greater and more beneficial effect than would have been achieved if we had been switching colors and responses from the beginning. Our ultimate goal is not to teach specific responses to specific situations, but to instill an ability to adapt, think and perform no matter what the situation. This task can be done with two hands or with two different fingers of the same hand.

  Up until now most tasks we have used have presented a situation to the patient and then waited, for however long it took, for the patient to analyze, decide and respond. Our goals, of course, as I have stressed all along required improved speed and accuracy from the patient before the patient was allowed to advance, nonetheless no pressure to respond within set time limits has been exerted before now. With this next program from Foundations I entitled, Visual Tracking, the additional stress of performing within the time limit is now being introduced. This task moves along on its own and if the response is not made the program just continues on. The task however is more of a visual tracking than scanning task, as the task does require the user to focus on the end of a graphical line and follow it across the screen as it is being drawn. The line starts at the top left corner of the screen and is drawn in small increments across the screen. When the line reaches the opposite side of the screen, it drops down a couple of spaces and starts again from the left side. A pattern starting in the upper left screen corner and going across would resemble the lines of text on a book page as the task progressed. Whenever a light colored block appears on the line, the user must press the response button very quickly to indicate they have seen the block. The user has about one second within which to make a scorable response to each box. The speed of movement of the line is adjustable. Slower moving lines also allow longer time limits for making acceptable responses. Given this, even the most impaired patients can utilize this task. At any speed the user should be required to make 85% or greater scorable responses consistently. When this is achieved, the speed of the line movement should be increased and the challenge renewed. The pattern can be varied by the therapist.

A higher level of challenge was added to the new PSSCogReHab version '95 of the software. The therapist can choose an option by which the letter L or R is placed within the stimulus block indicating that the patient must respond on the left or right button.
There are patterns of performance we have observed fairly consistently with our patients. Performance is usually better on the first half of the screen, poorer at about 3/4 through the task and then better again at the end. This probably reflects fatigue, motivation level and varying attention. Pointing this pattern out and discussing it with the patient usually helps in developing a more even response pattern and an elevated level of attention. A second pattern of responding involves the manner in which the patient is able to cope with and handle error responses. Some people tend to lose their concentration or let frustration override their abilities when they miss a target. With some, it may take two or three additional target boxes for them to get back on track and with others they may never get back on track once they lose it. This program can bring out the frustration in just about anyone and at times we have witnessed this as physical aggression (i.e., hitting the table). These situations already provide very good opportunities to stop and talk with a patient about what they were experiencing and how we observed them to handle the situation. We even use the task as a way of exercising more appropriate coping responses that, through our counseling, we attempt to generalize to every day life. On this task the movement of the line can be stopped completely by simply holding down the response button. This does produce a chord sound and makes an error against the user, but it also allows them to collect themselves before proceeding with the task. We bring this into the format of counseling by saying this is the same thing you must do when you experience frustration everyday because people are talking too fast or things get too complex for you to follow. You can stop the situation by either asking the person to slow down or repeat themselves, or you can stop the frustration by temporarily removing yourself from it. On the therapy task, the patient can resume by releasing the button and continuing on. A calm, clear minded approach most definitely gets the best results here, providing a positive example to the patient of how to get the best from themselves in all of their daily functioning activities. These types of analysis and carryovers require facilitation by the therapist or they will not occur in most cases. It should be clear to see that the role of the therapist as an astute observer and wise counselor is as demanding as it is essential.

There are other eye movement exercise tasks that can be helpful to the patient, but one thing I have observed and learned over the years is that when the movement exercise is simply movement with no purpose associated with it (i.e., meaningless back and forth movement or simply track the moving object), the therapeutic results are simply not realized. The movement must be meaningful. In this task the eye movement is required to track the line in order to see the box, a situation for which the person must then make a motor response within a time limit. There is a purpose to the eye movement, cognitive analysis is taking place, and decision making is occurring that all together culminate in a response after which immediate feedback is provided. This is a complex set of activities.

The tasks from this lesson are a step more complex and they allow more opportunity for tying in discussion and counseling about daily life functioning. By this time in therapy, we usually begin having patients and their families talk about change and improvement in functioning they are beginning to notice at home. Depending upon the patient and the level of impairment, we are usually about six to ten weeks into therapy with the introduction of this lesson.

CART - Lesson 5

Managing Complex Intake and Output

In Lesson 5, I will introduce two new programs that serve as a starting point for our work-to-come with memory skills, but more importantly for now, they serve as a more complex environment within which to further develop the attention and executive sills we have been addressing in the previous lessons. Two additional programs within the area of visuoperceptual motor skills also serve a dual purpose of further developing attention and executive skills while simultaneously providing exercise for eye-hand coordination.

Colormatch

Colormatch is somewhat like the old concentration game played with a deck of cards in which the players turn cards over two at a time in order to make matches. With Colormatch, the computer presents an array of blocks on the screen (4X4 to 8X8 grid). The mouse arrow can be moved around the screen with the mouse. A press of the mouse button turns over (i.e., turns on) the block so that it becomes one of the possible colors. When two blocks are turned on, the computer checks for a color match. If the colors match the blocks remain turned on and if they do not, they revert back to the original black color. The exercise continues until all matches are made. The patient's score for this exercise is based upon the total number of attempts required to make all the matches. When the task is presented in its random generation format, such that the matches and colors are totally different each time, we ask patients to acquire sufficient skill that they can consistently make all matches in more than 40% to 50% accuracy. Also you may choose to set up 4 permanently assigned game boards on which the matches and colors are always the same for each board each time it is used. The 4 patterns can be used as a measure of a person's ability to learn or profit from repetition. Randomly generated boards also remain as an option.

When we begin this task with a patient, we explain the task and instruct the patient as to how to move the arrow and turn over blocks. We then sit back and watch the patient perform the task without any interference or further instructions. Our purpose in doing this is to observe the approach and strategy the patient develops and utilizes to accomplish the task. Most often, the patient exhibits a skip-around-the-board guessing type of approach and will usually admit, in follow up discussions, that they did not really think out a strategy. This provides an opportunity to guide the patient into thinking about the nature of the task and about organizing and structuring a response strategy. Once again, this should not be spoon fed; the patient should be guided into coming up with strategies themselves. Even if the strategy developed by the patient is not the best, allow them to try it and then begin the thinking and explaining process again through discussion, and guide the patient to develop another strategy or improve on the old one.

For Colormatch, one of the best strategies that has led to the lowest scores is listed out stepwise below. The steps refer to figure 1 which shows the game board display, but with the blocks numbered. The blocks are not numbered on the computer screen.
Colormatch strategy:

  An organized, structured approach almost always produces better outcomes on most any task one is doing. The patient should hear this and talk about this for many therapy tasks to come until it is permanently imprinted. Even before this imprint should be one that says "you should always analyze a task and develop a strategy before you start."

Using the pattern option on Colormatch we have introduced a twist especially for those who have more difficulty with the regular random Colormatch. We start the patient with one of the set patterns and stick with it until the patient can complete it with a 100% accuracy. We do not tell the patient they are getting the same pattern each time. Rather we watch to see how long it takes them to realize it. One of our patients with severe frontal lobe impairment never did realize he was performing the same task even after many weeks of work on it. By keeping a record of successive scores on the set pattern version of Colormatch, the therapist can obtain a measure of how well a patient learns, since the task becomes a repetitive learning task. Unimpaired persons should be able to perform the 4X4 grid by the fourth repetition, the 6X6 grid by the sixth repetition and the 8X8 grid by the fifteenth repetition.

Trail Trace

The Trail Trace program can be found on SoftTools, Volume 15, Issue 3. There is a great deal of flexibility available to the therapist for setting up the game board display and the complexity of the task pattern. This game board appears on the screen as a 15 by 15 grid of small boxes. There is a point marked in the center box that represents the starting point of the task. The therapist can choose for the pattern, to be learned by the patient, to consist of 2 or more steps. We typically start a patient with 5 steps and advance them over a period of several therapy sessions (this may involve several weeks) to the level of 25 steps. The patterns generated by the program are random and therefore different each time the task is done. The good score at any level can be determined by squaring the number of steps. Therefore a 5 step pattern should be learned in 25 or less moves and a 25 step pattern should be learned in 625 or less moves.

The task starts with the patient sitting at the starting mark in the center block. The patient has a choice of moving in one of four directions via the direction keys on the screen. Movement choice is at first, and for each new move, trial-and-error. If the patient's choice for the move is correct, the computer draws a line from the center of the current box position to the center of the new box. The patient is then positioned at the center of the new box and it becomes the current box. After the first move, for which there are four choices, the patient has three choices for each subsequent move. The next step will never return immediately to the box just vacated. The pattern, however, may cross itself or even trace over itself, but only from forward movement not from backing up.

If the patient's choice of movement to the next position is incorrect, the computer buzzes. All of the pattern lines already discovered are erased and the patient is started over from the beginning in the center square. The patient then should retrace through all of the pattern already learned in order to get back to where they previously were located. Then a different choice should be attempted for the new box. When the entire pattern is produced without error, whether it requires 5 steps or 25 steps the task ends and the number of moves required to complete the pattern is reported.

As with Colormatch, the therapist should observe the patient perform this task several times at the 5 step level to see if a plan or strategy is developed and utilized. Simply guessing each new move may occasionally produce lower scores when the number of steps is low, but performance is usually inconsistent with this strategy. Without a predetermined plan, we find many patients choosing the same wrong move each time they retrace to the last known box. The strategy I like best goes like this:

To apply this, one must orient him/herself as though he/she were actually walking the grid him/herself, as the direction relative to the computer screen does not mesh with this simple strategy.

  Some people attempt to convert this task from a visual/motor learning experience to a verbal learning experience by memorizing the "ups, downs, lefts and rights" required. I try to discourage this, as the task was intended to be a visual and motor experience.
We start a patient at the 5 step level and attempt to make jumps of 5 step increments as the patient progresses. If this appears overwhelming during the initial attempt at the updated levels, we will back off to a 2 or 3 point increment. Almost all of our patients master the 25 step assignments to criterion (i.e., less than 625 moves). It may take 8 to 10 weeks for some patients to achieve that skill level, while others may master it is as few as 3 to 4 weeks.

CART - Lesson 6

Even More Attention and Executive Skills

    Visual Reaction Multiple Stimuli
   
To start out Lesson 6 we will revisit an old program format, but on a more complex level. The very first task of Lesson 1 was the Simple Visual Reaction task in which the patient visually monitored the screen for the appearance of the yellow block. Our first Lesson 6 task is from the Foundations II diskette and is item 1 from the menu entitled Visual Reaction Multiple Stimuli. The task is identical to the Simple Visual Reaction task except for the fact that there are three blocks (can be modified for nine blocks) presented simultaneously on the screen instead of just one. The user monitors for the simultaneous appearance of two or more yellow blocks on the screen. When these conditions are met, the appropriate response is to push the button as quickly as possible. A press when fewer than two yellow blocks are presented or for any other color combination, produces an error. If you can remember our instructions from Lesson 1, we had the user to focus on the spot at center screen and we asked that the user maintain this focus throughout the task making use of a whole visual field, rather than just central vision. We want the same setup for this task. The user must determine if the target colors are present without looking around the screen.

Having to do more analysis and to make a more complex decision will require a little more time than required for the simple visual reaction, so here we are looking for a reaction time of about .4 seconds compared to the .3 time we looked for on the Simple Visual Reaction program. When this program is first introduced, the user will have to resist the urge to press when there is only one yellow block. A second false target with which we have seen some patients struggle, is the situation when there are two or more of another nonyellow color.

Complex Attention (Even/Odd)

The next program we introduce in this series is also from Foundations II. The program entitled Complex Attention (Even/Odd) requires that the user develop a strategy and also requires some basic addition operations. The user must also know or be taught the concept of even and odd numbers. The task is as follows. Three single digit numbers are displayed on the screen in large print. When the three digits appear, the user must quickly determine if the sum of the three digits would produce an even or odd number, and then click on the Even or the Odd button on the screen to indicate whether they think the sum is even or odd. The user is being timed from the point of the appearance of the digits, until the Even or Odd button is pressed. As with all of these tasks, our purpose is to enhance the thinking skills of the patient. Therefore, we do not tell the patient strategies, but rather we guide them into thinking about the task and into developing their own strategy. If we recognize that the strategy developed is not the most efficient or even that it would not work at all, we allow the patient to attempt it and then help them profit from the feedback to alter the strategy or develop a new one.

There are two primary strategies that can be utilized to efficiently perform this task. The first is obvious from the instructions which imply that one should add the numbers together. This is the strategy I prefer and with which I can get the best scores; however, we have had a number of patients who performed the task much better utilizing the second primary strategy. The rules of this strategy state that if there is an odd number of odd numbers the sum must be odd. The only thing one has to do then is count the odd numbers. If there is one or three odd numbers the response would be odd, otherwise the response would be even. No matter which strategy the patient applies at first, have them come up with a different strategy as part of this exercise. Then have them apply one strategy one run through the whole program, and the second strategy on the next run through.

Some of our patients, especially some of the children, were weak on their even/odd number concepts, requiring that we attend to this aspect of the task before fully implementing this as a therapy task. Utilizing objects such as marbles or coins, we demonstrate even and odd numbers of marbles or coins and have the person identify the proper concept. Then we rehearse with flash cards. No matter how large a number may be, it is the right most or one's digit that determines if it is even or odd so only the single digits 0-9 need to be used to train the concept. Then, the right most digit rule is taught and from that point, the person should recognize even or odd for any size number. For those who continue to experience problems, we place a vertical strip of paper on the left side of the monitor with the even digits and a vertical strip on the right side of the monitor with the odd digits.

Visual Scanning II

During the mid eighties we began getting a number of referrals of learning disabled (LD) and attention deficit disorder (ADD) children. We had taken on such a case, more or less as an experimental situation at the request of the child's parents and had experienced very good results with this child. Information about this project traveled through the grapevine just by word of mouth and the referrals came pouring in. Recognizing that some of the problems demonstrated by these kids had a slightly different twist than those seen with our head injured patients, I began developing some of our software to take these twists into account. The Visual Scanning II program was one of the first of this group of programs. I noticed that many of our patients, head injured, learning disabled, etc. would focus their visual attention to very specific aspects of the stimulus and overlook or not recognize other details of the same stimulus. There are levels of detail for any stimulus situation that requires a narrowing of focus as the detail is smaller or more complex, and a combining of detail into larger gestalts as one looks at the stimulus situation as larger parts or as a whole.
In designing the Visual Scanning II task, I wanted several obvious levels of detail, and I wanted to force the patient to narrow and broaden their focus in order to do the task. The task is as follows. A punctuation mark is displayed at the bottom center of the screen. This character is the target for which the patient will have to search. After a brief pause, ten stations of numbers appear, each with a punctuation mark in its center. The patient must quickly find the station that contains the targeted punctuation mark. Then the patient must look at the station itself and respond by clicking on the number at the bottom of the screen that makes up the station.

The whole stimulus is represented by the screen of ten stations. At this level the patient must develop a search strategy. A helter skelter random look around the screen may occasionally result in finding the target faster, but on the average this is a poor strategy. The use of a pattern such as left to right scanning pattern such as is used for reading is a good technique. Also, the use of a circular pattern appears efficient I have also seen some patients who were able to take in the whole screen without moving their eyes and go directly to the target. From this attention to the whole gestalt, the patient must narrow their focus to the center of the stations in order to identify the characters as they search for the target. Once the target has been found, the patient must broaden their focus to the level of the station itself in order to determine what number it is made of. Then finally, the patient must click on this number at the bottom of the screen.

Performance is noted on speed and accuracy. Many of our learning disabled kids show a pattern of making excessive errors. Along with this, we have noticed reaction times that were absolutely too fast for the kids to have searched the screen for the target With this kind of information in hand, we have been able to confront guessing behavior or misperception caused by trying to rush a response.

Visual Scanning III

The Visual Scanning III program was also developed with the special characteristics of the LD and ADD kids in mind. This task presents a column composed of blocks of alphabet characters on each vertical border of the screen (left and right sides). A highlighter points to one of the blocks of letters on the left side and an arrow in the center of the screen points to the column on the right side. A highlighter on the side to which the arrow is pointing (the right side at this point) can be moved up and down the column by clicking on the arrow keys. The patient must move the highlighter until it points to the same block of letters highlighted behind the arrow. A click on the horizontal arrow by the patient indicates to the computer that the patient has found the block. Immediately the patient receives feedback about the correctness of the response and the computer highlights a new block on that side and switches the arrow to point to the opposite side. The patient then shifts back to the opposite side to make the next response. After each trial this flip flops to the opposite side occurs until the whole task is completed. For half of the trials, the patient then takes information from the left side of the screen in order to make a response on the fight side of the screen. The other half of the trials requires that information from the right side be used for a response on the left side of the screen.

Our head injured patients tend to show a response pattern in which performance in either direction is slow at first. Our LD and ADD kids most frequently show a pattern in which they perform much better going left to right than right to left. We also see them have reaction time on error trials that were too fast for them to have made an honest effort to get to the correct response. Again, having this evidence with which to confront them is invaluable in changing this behavior.

Simultaneous Multiple Attention

This task starts out requiring the patient to maintain vigilance on one line of colors that march across the screen from left to right. A target color, highlighted at center of screen, is the stimulus the patient is awaiting to appear on the line. Once the target color enters the line from the left side, the patient must monitor its movement until it is highlighted in the target square at center screen. The patient then clicks on the target screen.

Once the patient is able to perform this single line to criterion, a second line marches across the screen as well. The patient then monitors both lines for the target. A third line is introduced with further mastery that also travels left to right across the screen. On the final level, a fourth line is added to the display, but this one moves across the screen from right to left while the other three continue the left to right movement. The object is to capture all the target colors on all the lines. This, of course, requires the simultaneous monitoring of all four lines.

There are no special strategies here except to remain calm and open minded so as to reduce frustration and to avoid becoming overwhelmed with the demands of the task. Actually, when patients can get themselves into this cairn, open minded and flexible frame of mind they find they can do many tasks they had not been able to do and generally function better. This should be pointed out to the patients frequently in an effort to have them acquire this frame of mind as their standard mode of operation.

Remember, our goal is to get the patient to be able to think and operate for themselves. Do not spoonfeed. The patient should develop skills and strategies on their own with as little guidance from us as is required to accomplish this.