Slow & Steady, Step by Step Is it possible to teach executive-function skills to people who have brain injuries? Absolutely, says cognitive rehab clinical researcher McKay Sohlberg. She shares insights on how it’s possible to help these patients resume their daily routines. Features
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Features  |   May 01, 2015
Slow & Steady, Step by Step
Author Notes
  • Shelley D. Hutchins is content producer/editor for The ASHA Leader. shutchins@asha.org
    Shelley D. Hutchins is content producer/editor for The ASHA Leader. shutchins@asha.org×
  • McKay Moore Sohlberg, PhD, CCC-SLP, is the director of the communication disorders and sciences program at the University of Oregon and co-director of the university’s cognitive rehabilitation clinic. She is an affiliate of ASHA Special Interest Groups 2, Neurophysiology and Neurogenic Speech and Language Disorders; and 18, Telepractice. mckay@uoregon.edu
    McKay Moore Sohlberg, PhD, CCC-SLP, is the director of the communication disorders and sciences program at the University of Oregon and co-director of the university’s cognitive rehabilitation clinic. She is an affiliate of ASHA Special Interest Groups 2, Neurophysiology and Neurogenic Speech and Language Disorders; and 18, Telepractice. mckay@uoregon.edu×
Article Information
Attention, Memory & Executive Functions / Traumatic Brain Injury / Features
Features   |   May 01, 2015
Slow & Steady, Step by Step
The ASHA Leader, May 2015, Vol. 20, 44-52. doi:10.1044/leader.FTR2.20052015.44
The ASHA Leader, May 2015, Vol. 20, 44-52. doi:10.1044/leader.FTR2.20052015.44
McKay Moore Sohlberg believes that all speech-language pathologists, regardless of their specialty or workplace, essentially teach for a living. Most obviously, Sohlberg instructs graduate students how to be SLPs. (She is director of the University of Oregon’s master’s program in communication disorders and sciences.) But, as co-director of the university’s cognitive rehabilitation clinic, she also helps patients relearn cognitive skills.
“At the end of the day we are teachers—whether you are providing instruction on speech, language, swallowing or cognitive strategies, you are trying to teach someone a behavior or skill,” says Sohlberg, who has been researching and developing cognitive rehabilitation methods for 30 years. “I’m passionate about working with people who’ve had some kind of acquired insult to their brain. My goal is to help improve their day-to-day functioning.”
In Sohlberg’s case, those skills relate to improving executive functions: a set of cognitive or mental processes coordinated in the brain’s frontal lobe that help us reason and problem-solve. They include complex abilities related to initiation, planning and self-monitoring. They are the skills we need to manage and organize time, set priorities and complete goal-directed activities.
Sohlberg works with patients with acquired cognitive brain impairments caused mostly by traumatic brain injury, diseases and strokes. She teaches them to regain their executive function, among other cognitive processes, so they can successfully finish school, restore and maintain social relationships, or even ride the bus again.
One of her approaches includes systematic instruction techniques that works so well she used it to teach her three teenage daughters to drive without a tear shed or voice raised. In addition to this and other attention-training methods, Sohlberg helps patients compensate for skills they might not relearn. She works with computer scientists to develop devices and software that help patients improve attention, focus, organization, memory and other aspects of executive function.
The Leader asked Sohlberg to share her methods for helping patients and students learn the skills they most need.
Q How did you become interested in acquired brain injury rehabilitation?
When I graduated with my master’s [in speech-language and hearing sciences] in 1984, the field of post-acute brain injury rehab was just beginning. My first job out of graduate school at Good Samaritan Hospital [Puyallup, Washington] gave me an opportunity to work with this population—people not previously on the forefront for receiving services and for whom the current state of thinking was that they could not improve. My hospital was one of the original programs that developed a continuum of care from inpatient, outpatient, day treatment to residential. We showed that people could improve even years out from the injury.
I became hooked on post-acute rehab. I witnessed the cognitive underpinnings of behavior and adjustment and learned how to implement therapies that could improve damaged cognitive processes or allow people to compensate for them, based on what we knew about cognitive functioning or from initial research findings.
We developed practice-based evidence and then began to contribute to evidence-based practice. Equally important to the development and evaluation of cognitive interventions was what I learned about the context for implementing the therapy—the need to look at every individual in a holistic way, and the power of collaboration and therapeutic alliance.
These therapy practices were instilled from my experiences at Good Samaritan. The years I directed the brain injury community re-entry programs have influenced every aspect of my career. My work since then has been to deepen that evidence base. It’s exciting to be looking at how cognition is organized in the brain. And to help people who struggle to do what they want to do and come up with strategies and then try them out.
Q You are particularly interested in helping people regain attention, memory and executive function. Why do you concentrate on those specific topics?
Impairments in those cognitive areas are most common after brain injury and they’re show-stoppers in people being able to do what they want to do. If we can figure out ways to boost processing or learning or help people compensate, they can re-enter their lives in meaningful ways.
People who have impairments in these areas often use devices or tools that will help them, like smartphone apps that aid memory and organization, or electronic readers. The technology I help develop allows them to compensate for their cognitive impairment. Some of my work, however, such as developing computerized attention training programs, does not seek to compensate, but to improve attention processing.
We hope to improve people’s underlying impairments enough to improve day-to-day activities. The biggest challenge is encouraging generalization in clients sotheir improvements on the drills transfer to improvements on real-world tasks. To achieve this, we always pair drills with strategy training.
Q What are some examples you can share about why these skills are so important?
Working on cognitive rehabilitation provides a meaningful practice. Even small changes in someone’s cognitive abilities produce extreme disruptions in their quality of life. An example is patients with concussion. Most people completely recover, but there’s a significant group that experiences persistent cognitive impairments. And while this impairment might be measurably mild, it greatly impacts their ability to do things like complete schoolwork and get a degree.
Q From your research and clinical practice, what approaches work best with cognitive rehab?
A specialty of mine is developing and evaluating ways to instruct people who have cognitive impairments so they can learn or relearn tasks and strategies. That’s led me to get on a soapbox about SLPs being effective instructors. We’re always trying to teach someone a skill and we all need to learn more about systematic instructional techniques to better teach our clients.
Systematic instructional techniques that facilitate this learning, particularly for people with cognitive impairments, to me is one of the most critical skills for SLPs. The technique can be applied to any cognitive rehab treatment.
The procedures consist of defining the target, analyzing the goal task, minimizing errors when you are training, providing high rates of correct practice and promoting self-monitoring as the person learns the skills. These are the critical instructional components. Implementing them is harder than it sounds, but it’s critical.
Implementing systematic instruction involves techniques to break down the target training material and present it in ways that the learner can more deeply encode it. It also involves strategies to help the learner engage in the training process and relies upon setting goals that are meaningful to the patient.
These instructional techniques are particularly useful for people with learning challenges due to memory impairments after an acquired brain injury. However, careful instruction that involves continual monitoring of learning outcomes and generalization is helpful for patients with a variety of cognitive challenges, including executive functions. My colleague Lyn Turkstra and I wrote a textbook, “Optimizing Cognitive Rehabilitation: Effective Instructional Methods.” The book describes training procedures and data collection for using systematic instruction to teach people who have acquired cognitive impairments a range of skills, including metacognitive strategies, assistive technology and social communication.
Q Can you share an example of implementing your systematic instructional techniques?
I used these instructional techniques not just with clients, but my own children. I’m famous—or maybe infamous—for being able to teach teenagers—including my three daughters—to drive!
Before they ever leave the garage, they have a task-analysis, ready-set list of checking mirrors, seatbelt, key press and foot on brake. Once they accomplish the ready-set routine fluently, without error—and after 24 hours—then we leave the garage.
Following proper sequencing, I teach braking next. I never train brake and gas pedal together, as I want a strong braking reflex. I drive to the top of a small incline and they drive down the hill repeatedly tapping on the brakes on the way down. I drive to the top and then we repeat that until they’re completely smooth with the braking process. After 10 trials, each 15 minutes max, they usually get enough practice that we add the gas pedal. Then we have the ready-set routine, breaking and gentle gas, so we drive on a straightaway in the parking lot.

The commonality is helping people better do the activities most meaningful to them so they can resume their roles in society.

This is an errorless method and there are no arguments, no trial and error. It’s very fun and no one is yelling or unhappy.
I have a rather dramatic younger daughter and she’d just lift her hands and put them over her eyes when something went wrong. We’d isolate the error and do mass practice, so with her, no matter what, she was never allowed to take her hands off the wheel. This is an example of individualizing the task sequence.
Q What success have you had developing new rehab techniques?
I’m really proud of my work in attention training. I’ve helped develop intervention tools that clinicians can use to improve attention that also facilitate generalization and evaluating generalization. That’s an area based on attention theory that looks at whether improving attention impacts quality of life. We just published our pilot study (see sources).
My former doctoral student Gina Griffiths and I just put out two papers on evaluating the efficacy of training adults with brain injury to use reading comprehension strategies. This work resulted in a program that delivers these reading comprehension strategies. We start with looking at the needs real people have in reading and retention, like being able to retain information, so they can go back to school.
Q What are some of the assistive technologies you’ve developed to help those with an acquired brain injury reintegrate into society?
When we’ve looked at developing therapies for people, we’re looking for ways we can help them do things that are meaningful to them. That drives a lot of our work. And for one person that might be that they’re living in a long-term facility, so maybe they need an e-mail program to keep in contact with family and friends. For another, it might be returning to college and getting a degree, so it’s adequate school performance.
The commonality is helping people better do the activities that are most meaningful to them, so they can resume their roles in society.

When we’ve looked at developing therapies for people, we’re looking for ways we can help them do things that are meaningful to them. That drives a lot of our work.

Q How does rehab for people with acquired cognitive impairment differ from that for those with a developmental issue?
Those with acquired impairments have some foundation from what they learned before. For example, they usually know how to read, so you have a starting point. It’s not often that someone who has an acquired brain injury loses the ability to read. They might have a memory or attention impairment, so they can’t retain or integrate the text. So you teach sustained attention strategies or drills for reading retention based on old learning or special review strategies. With acquired brain injury, you can see what’s preserved and build on that to help them improve other cognitive function.
That said, there’s a different psychology to loss and changes in identity and roles. Cognition can’t be isolated from helping people cope with loss. It can’t be treated in isolation. SLPs have to be skilled in this knowledge to work with cognitive rehab.

With acquired brain injury, you can see what’s preserved and build on that in order to help clients improve other cognitive function.

Q What is your most important work?
I believe my largest contribution has been participating in the development of evidence-based practice guidelines for traumatic brain injury. It’s an ongoing endeavor involving lots of people and resulting in numerous articles. We attempt to distill research and inform clinicians, so they can use these guidelines for rational clinical decision-making. Recently, I began serving on a panel to develop research practice guidelines for working with adults who have chronic, moderate-severe impairments following brain injury.
I think I have one of the best jobs imaginable. Being an SLP in this arena—I can’t imagine a better job. Working with people who are struggling to get their lives back after cognitive impairment I learn so much. Every week there’s at least one patient who inspires me and teaches me a critical lesson about my humanity.
Q What advice would you give other SLPs treating clients with cognitive impairment or executive-function issues?
I think the single most important clinical skill for working with patients who have not only cognitive impairments but other communicative challenges is collaboration. This involves collaborative goal-setting with patients from the beginning of treatment and aligning ourselves with clients to help them engage in their therapy.
What drew you to specializing in cognitive rehabilitation?
Cognition cannot be treated in isolation. I think one of the reasons I was drawn to developing effective programs in this area is that it allowed me to work with the whole person before speech-language pathologists were given permission to go beyond the silos of speech and language. It’s interdisciplinary in nature and we need to integrate our treatment with the psychosocial consequences of a patient’s changed abilities. It’s a very heterogeneous population with diverse needs that must be simultaneously considered.
What are some primary causes of acquired cognitive impairment?
People with traumatic brain injury, but also disease—brain tumor, stroke, etcetera. I work less with people who have progressive illness like Alzheimer’s. I’ve primarily worked with folks in the post-acute phase of rehabilitation—people trying to function in their communities at the highest level. This is after people have left the hospital and are back home.
You do a lot of collaboration with computer scientists. How does that process work? What projects have you completed with those colleagues?
Once of the best cups of coffee I ever accepted was from one of our computer science professors, Steve Fickas, who wanted to find out if there were projects his software engineering students could do in our department. He heard about some of our work in our cognitive rehabilitation clinic and wanted to see if software engineering students might be able to gain programming experience solving problems that real people have using technology. This spawned a wonderful collaboration.
Our work led to the development of adapted e-mail systems, public transportation prompts, electronically delivered reading comprehension systems, computerized attention-training therapies with homework that send practice data back to the clinician, television prompting programs, systems that people with very severe amnesia can use, and the like.
We find challenges that really address clients’ actual needs and then we typically form user groups that are similar to focus groups, so that people with the impairment are involved from the beginning. First, we create a prototype, then we test it with patients, then update it, then clients use it again and we update it again until it works. Real people use the devices and give feedback to inform the design. This process ensures that the final device or program will be highly usable by those who need it. Partnerships with these end-users during design and evaluation are key to our successes.
My systematic instruction techniques really grew out of my line of research, development and evaluation in assistive technology for cognition. Once you have these devices or programs, you need to be able to teach others how to use them.
Sources

Cognitive Rehab Programs/Products

Sohlberg, M. M., Fickas, S., & Prideaux, J. (2010). CogLink; Accessible email for people with severe memory impairments. Life Technologies, LLC.
Sohlberg, M. M., Fickas, S., & Prideaux, J. (2010). CogLink; Accessible email for people with severe memory impairments. Life Technologies, LLC.×
Sohlberg, M. M. & Mateer, C.A. (2010). Attention Process Training-3. Wolfeboro NJ: Lash and Associates.
Sohlberg, M. M. & Mateer, C.A. (2010). Attention Process Training-3. Wolfeboro NJ: Lash and Associates.×
Sohlberg, M. M. (2007). Deficits in self awareness following brain injury; and Managing memory impairment following brain injury. Tip Card Sets for Caregivers of People with Severe Memory Impairments. Wolfeboro, NJ: Lash and Associates Publishing and Training.
Sohlberg, M. M. (2007). Deficits in self awareness following brain injury; and Managing memory impairment following brain injury. Tip Card Sets for Caregivers of People with Severe Memory Impairments. Wolfeboro, NJ: Lash and Associates Publishing and Training.×
Sohlberg, M. M., Johnson, L., Paule, L., Raskin, S., & Mateer, C. (2001). Attention Process Training II. An attention training program for persons with mild brain injury. Wolfeboro, NJ: Lash & Associates Publishing & Training.
Sohlberg, M. M., Johnson, L., Paule, L., Raskin, S., & Mateer, C. (2001). Attention Process Training II. An attention training program for persons with mild brain injury. Wolfeboro, NJ: Lash & Associates Publishing & Training.×
Sohlberg, M. M., Todis, B., Glang, A. (1999). Changes in self-awareness among students with brain injury; Part of an educational booklet series. Wolfeboro, NJ: Lash & Associates Publishing & Training.
Sohlberg, M. M., Todis, B., Glang, A. (1999). Changes in self-awareness among students with brain injury; Part of an educational booklet series. Wolfeboro, NJ: Lash & Associates Publishing & Training.×
Cognitive Rehab Books by Sohlberg
Sohlberg, M. M. & Turkstra, L. (2011). Optimizing Cognitive Rehabilitation: Effective Instructional Methods. New York, The Guilford Press
Sohlberg, M. M. & Turkstra, L. (2011). Optimizing Cognitive Rehabilitation: Effective Instructional Methods. New York, The Guilford Press×
Sohlberg, M. M. & Mateer, C. (2001). Cognitive Rehabilitation: An Integrated Neuropsychological Approach. New York: Guilford Publication.
Sohlberg, M. M. & Mateer, C. (2001). Cognitive Rehabilitation: An Integrated Neuropsychological Approach. New York: Guilford Publication.×
Sohlberg, M. M. & Mateer, C. (1989). Introduction to Cognitive Rehabilitation: Theory and Practice. New York: Guilford Press.
Sohlberg, M. M. & Mateer, C. (1989). Introduction to Cognitive Rehabilitation: Theory and Practice. New York: Guilford Press.×
1 Comment
May 13, 2015
Jennifer Hatfield
Love the article
Absolutely love this post. I too share a passion for working with this population for the very same reasons. Being able to partner with the client to provide true client-centered care is truly wonderful. Thank you for such a detailed post.
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