Rehabilitation of Children and Adults With

Cognitive-Communication Disorders After

Brain Injury
Mark Ylvisaker, Robin Hanks, and Doug Johnson-Greene

Reference this material as: American Speech-Language-Hearing Association. (2003). Rehabilitation of

Children and Adults With Cognitive-Communication Disorders After Brain Injury [Technical Report].
Available from www.asha.org/policy.
Index terms: rehabilitation, cognitive-communication, brain injury, neuropsychology
DOI: 10.1044/policy.TR2003-00146

© Copyright 2003 American Speech-Language-Hearing Association. All rights reserved.

Disclaimer: The American Speech-Language-Hearing Association disclaims any liability to any party for the accuracy, completeness, or
availability of these documents, or for any damages arising out of the use of the documents and any information they contain.
Rehabilitation of Children and Adults With Cognitive- Technical Report
Communication Disorders After Brain Injury

About This This technical report was prepared by Mark Ylvisaker, Robin Hanks, and Doug
Document Johnson-Greene, on behalf of the Ad Hoc Joint Committee on Interprofessional
Relationships of the American Speech-Language Hearing Association (ASHA)
and Division 40 (Clinical Neuropsychology) of the American Psychological
Association (APA). ASHA representatives included Pelagie Beeson, Susan Ellis
Weismer, Audrey Holland, Susan Langmore, Lynn Maher, Diane Paul-Brown (ex
officio), and Mark Ylvisaker. Alex F. Johnson, ASHA vice president for
professional practices in speech-language pathology (2000–2002), was monitoring
vice president. APA representatives included Kenneth Adams, Sharon Brown, Jill
Fischer (chair, 1997–1999), Robin Hanks, Doug Johnson-Greene, Sanford
Pederson, Steven Putnam, and Joseph H. Ricker (chair, 2000–2002). The ASHA-
Special Interest Division 2 (Neurophysiology and Neurogenic Communication
Disorders) Working Group on Cognitive-Communication also assisted with the
development of this report. Working group members are Lynn Maher (chair), Ron
Gillam, Leora Cherney, Dava Waltzman, Mary Kennedy, Mark Ylvisaker, Diane
Paul-Brown (ex officio), and Alex Johnson (monitoring vice president). The
technical report was approved by ASHA's Executive Board (EB 35-2002).

****

Introduction Professionals from diverse disciplines, including clinical neuropsychology and

speech-language pathology, provide cognitive rehabilitation services. The
functional domains affected by cognitive disability—such as activities of daily
living, communication, learning and academic performance, vocational
performance, behavioral self-regulation, and social interaction—extend into the
scope of practice of many rehabilitation professions. Therefore, cognitive
rehabilitation has been aptly described as a collaborative service (American
Speech-Language-Hearing Association, 1995).

This report was developed to examine two theoretical paradigms, based on relevant
theory, available empirical studies, clinical experience, and trends in service
delivery and reimbursement. The specific purposes of this report are threefold: (a)
to explore the historical and conceptual foundations of cognitive rehabilitation for
individuals with brain injury; (b) describe alternative paradigms for service
delivery; and (c) promote studies examining efficacy of cognitive rehabilitation,
particularly studies that employ novel and theoretically sound paradigms. It is
beyond the scope of this report to systematically review the efficacy literature.
Readers are directed to Carney and colleagues (1999) and Cicerone and colleagues
(2000) for evidence reviews.

Although this report was developed to address service issues related to individuals
with cognitive impairments associated with acquired brain injury, the theoretical
and practical considerations apply equally to children and adults whose
impairments are congenital. Indeed, theory construction and clinical research have
a longer history in work with the latter population. Mann (1979) and Kavale and
Forness (1999) discuss the distinction between process-oriented and context -
sensitive approaches applied to developmental disabilities and special education,
and summarize relevant literature.

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Specific definitions of cognitive rehabilitation typically include assumptions about

cognition or rehabilitation that can be disputed. Nevertheless, discussion of a topic
should begin with a general characterization of the topic. The following definition
of cognitive rehabilitation is taken from the widely distributed 1998 NIH
Consensus Statement on Rehabilitation of Persons With Traumatic Brain Injury:

The goals of cognitive and behavioral rehabilitation are to enhance the person's
capacity to process and interpret information and to improve the person's ability
to function in all aspects of family and community life. Restorative training focuses
on improving a specific cognitive function, whereas compensatory training focuses
on adapting to the presence of a cognitive deficit. Compensatory approaches may
have restorative effects at certain times. Some cognitive rehabilitation programs
rely on a single strategy (such as computer-assisted cognitive training); others use
an integrated or interdisciplinary approach. A single program can target either an
isolated cognitive function or multiple functions concurrently (NIH, 1998).

Later in this report we discuss the possible value of adding context-oriented

interventions to the scope of cognitive rehabilitation, including improving the
support behaviors of significant people in the person's environment and modifying
task and environmental demands in a way that enables a person with chronic
cognitive impairment to participate successfully in family and community life.
Using the most recent 2001 modification of the World Health Organization (WHO)
International Classification of Functioning, Disability and Health (ICF)
framework, these interventions would fall under the heading, Contextual Factors/
Environmental Factors (WHO, 2001). We also return later to a theme introduced
in the NIH statement, that the distinction between restoration and compensation
may not be as clear as past discussions have suggested.

Rationale for The modern history of cognitive rehabilitation for individuals with brain injury
Reconsidering the extends as far back as World War I, when large numbers of soldiers and civilians
Theoretical needed comprehensive rehabilitation after war-related traumatic brain injury
Foundations for (TBI). Cognitive rehabilitation in the United States gained momentum during the
Cognitive 1970s, with the organization of emergency medical services and consequent
Rehabilitation increases in survival rates following severe TBI. As a discrete service, cognitive
rehabilitation came to be associated with rehabilitation programs developed jointly
by the Israeli Ministry of Defense and the New York University Institute of
Rehabilitation Medicine after the 1973 Yom Kippur war (Boake, 1989). Cognitive
rehabilitation has become a common rehabilitative service for survivors of TBI in
both acute and postacute rehabilitation settings, following proliferation of
rehabilitation programs in the 1980s.

Cognitive rehabilitation, as currently conceptualized, is a service that has been both

widely praised and criticized. There may be several reasons for the controversial
nature of this service. First, because it has no clear professional home, individuals
with varied educational backgrounds who may use many different conceptual
frameworks deliver cognitive rehabilitation services. In such circumstances,
controversies about the nature of the service and its method of delivery are almost
inevitable. Second, there currently exist no generally agreed-on standards of
clinical practice in this area of service delivery, despite an initial attempt by the
Interdisciplinary Special Interest Group of the American Academy of
Rehabilitation Medicine to establish basic guidelines for cognitive rehabilitation

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(Harley et al., 1992). Third, studies of treatment efficacy tend to be

methodologically weak and frequently report ambiguous results (Carney et al.,
1999; Park & Ingles, 2001). Finally, in some settings the service has been
trivialized by indefensible practices implemented by inadequately trained
practitioners (e.g., unsystematic exposure of clients to video games or other games;
haphazard use of workbooks and cognitive retraining software on the often
unsupportable assumption that engagement of a cognitive process in cognitive
exercises will improve that process and thereby improve performance on real-
world tasks that involve the process).

These controversies have led many critical observers, including many referring
physicians, health insurance and health maintenance companies, state and federal
oversight bodies, and consumers of rehabilitation, to question the service as lacking
an accepted theoretical structure and insufficiently supported by well-designed
studies of effectiveness, including evidence of meaningful impact on functional
outcome. Furthermore, the rise of managed care and other cost-containing efforts
in rehabilitation has created an atmosphere that does not tolerate services lacking
official standards of practice and firm empirical support, with emphasis on
functional outcome.

The Oregon Health Sciences University, under a contract with the Agency for
Health Care Policy and Research, recently conducted a systematic review of the
scientific literature dealing with the effectiveness of cognitive rehabilitation. This
review identified very few reasonably controlled studies that yielded evidence
supporting the effectiveness of cognitive rehabilitation in relation to functional
outcome (e.g., employment, social reintegration; Carney et al., 1999).
Furthermore, studies restricted to intermediate measures of outcome (e.g.,
performance on neuropsychological tests or customized laboratory measures)
produced mixed results. A more recent review (Cicerone et al., 2000) yielded more
positive results. However, it is likely that the inclusion of interventions targeting
specific domains of content (e.g., language intervention for individuals with
aphasia and social communication limitations) is partially responsible for the
relatively optimistic conclusions of this systematic literature review.

Methodological weaknesses and inconsistencies abound in this growing body of

efficacy literature. However, they can be charitably interpreted as the natural
consequence of the relative youth of the field, extraordinary diversity within the
population of people with cognitive disability, and varying conceptual frameworks
within which interventions have been designed and implemented. Lack of support
for an intervention does not constitute sufficient evidence to invalidate the
approach. It was within this context that our interdisciplinary committee chose to
examine possible alternatives to the conceptual framework that has dominated the
service of many, but not all, providers of cognitive rehabilitation.

Alternative We have chosen to describe two distinct conceptual frameworks for cognitive
Paradigms in rehabilitation by outlining their positions in five domains needed to define a
Cognitive comprehensive theory of intervention. These domains are outlined in Table 1.
Rehabilitation Within each domain, what has come to be understood as the “traditional approach”
to cognitive rehabilitation, that which dominated clinical activity during the early
years of active program development in the 1970s and early 1980s, is compared
to a “contextualized” paradigm, defined as a context-sensitive framework. The

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Table 1. Traditional and Contextualized Approaches to Cognitive Rehabilitation

latter approach has evolved in recent years as a consequence of (a) research and
clinical experience with individuals with TBI, (b) findings and theoretical
developments in cognitive science, and (c) reflection on related intervention
research and trends in fields with a longer history of service and outcome research
than cognitive rehabilitation for individuals with brain injury. In offering two
alternative frameworks, we recognize that all attempts to dichotomize complex
domains are fraught with peril and that clinicians often choose to serve individuals
using intervention strategies from alternative frameworks.

Throughout this discussion, the WHO definitions of body structure/function (i.e.,

impairment), activity/participation (previously two categories—activity reduction
[disability] and participation reduction [handicap]), and contextual factors were
chosen to describe the applications of the traditional versus the contextualized
paradigms (WHO, 1980; augmented in WHO, 1998, 2001). Within this
classification system, body structure/function limitations refer to the underlying
damage to psychological, physiological, or anatomic structures or functions (e.g.,
aphasia associated with perisylvian left hemisphere stroke). Activity/participation
limitation refers to an associated reduction in the ability of an individual to execute

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tasks in a standardized environment (i.e., capacity) or to perform functional

activities of everyday life (e.g., finding words during a conversation) in a natural
environment (i.e., performance), and contextual factors refer to a social, familial,
educational, vocational, or other role disadvantage associated with the disability
(e.g., failure in school or loss of a job due to the communication disability).
Contextual factors include both environmental factors (including attitudes of
individuals in the environment) and personal factors (including attitudes of the
person with disability). Context-oriented assessment and intervention would
explore the supports available in the environment and attempt to improve those
supports, including the support behaviors of significant people in the environment.

Goals of Cognitive Traditional Paradigm

Rehabilitation Within traditional cognitive rehabilitation, the primary treatment goal is to improve
an individual's performance by eliminating or reducing underlying cognitive
impairments (Ben Yishay, Piasetsky, & Rattok, 1987; Meier, Benton, & Diller,
1987; Sohlberg & Mateer, 1989). That is, the focus of intervention is the underlying
impairment and the goal is largely curative or restorative. With cure or restoration
of cognitive function as the goal, intervention is largely restricted to hierarchically
organized retraining exercises that target specific cognitive processes impaired by
the injury. Exercises may be augmented by pharmacologic intervention. In the
event of inadequate restoration of cognitive function with restorative exercises,
clinicians often attempt to help the individual acquire compensatory behaviors
(e.g., internal mnemonics or organizational strategies, self-cueing) or assistive
devices (e.g., memory books, pager reminder systems). These methods are
designed to reduce real-world disability despite enduring cognitive impairment.
Whether restorative or compensatory, the goal is to improve outcome by directly
changing the patient's impaired cognitive functions.

Contextualized Paradigm
Within a flexible and contextualized approach to rehabilitation, the broad goal is
to help individuals with cognitive disabilities achieve functional objectives and
participate in chosen activities that are at least temporarily blocked by the
impairment. Depending on a variety of factors, the approach might include any
combination of the following interventions:
• Body structure/function-oriented interventions designed to improve real-
world functioning by restoring cognitive functions with decontextualized
retraining exercises, if there is good reason to believe that retraining exercises
hold restorative potential.
• Activity/participation interventions designed to improve real-world
functioning by helping the individual to compensate for chronic cognitive
impairment, if there is good reason to believe that strategic compensation is
possible, and to improve performance of specific, functional tasks, thereby
reducing disability without necessarily reducing the underlying impairment.
• Context-oriented interventions designed to lessen the impact of cognitive
disability on real-world status and functioning by engineering the individual's
environment to reduce the impact of cognitive disability and by modifying the
expectations and supportive behavior of people in the individual's everyday
life (i.e., providing education, training, problem solving, and other forms of
support).

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With respect to breadth of focus, cognitive rehabilitation within the contextualized

paradigm is analogous to physical rehabilitation. That is, clinicians are accustomed
to making responsible decisions about combinations of body structure/function-
oriented interventions (e.g., surgery, pharmacology, physical exercises and
manipulations), activity/participation-oriented interventions (e.g., use of
compensatory motor patterns and prosthetic equipment) and context-oriented
interventions (e.g., environmental modifications, specialized supports provided by
others). Efforts of the physical rehabilitation team may have a profoundly positive
effect on an individual's success with everyday tasks without necessarily changing
the profile of physical abilities. Similarly, cognitive rehabilitation may be effective
in individual cases despite minimal change in cognitive impairments or even in
specific performance abilities.

Assessment for Cognitive, neuropsychological, language, and related assessments can serve many
Cognitive distinct and important purposes. Comments in this section are restricted to
Rehabilitation assessment designed exclusively for purposes of developing, monitoring, and
modifying intervention plans for children and adults with cognitive impairment
after brain injury.

Traditional Paradigm
Within the traditional approach, assessment is generally centered around a battery
of tests of neuropsychological/cognitive functioning, resulting in judgments about
areas of cognitive weakness that need to be strengthened and areas of strength that
can be used to compensate for ongoing weaknesses. Often the same standardized
tests and laboratory tasks that are used to create a profile of abilities and disabilities
are also used to measure responses to treatment. This approach to assessment is
consistent with a view of cognition in which discrete processes can be measured
separately and strengthened with exercises, and when strengthened, support
improved performance of tasks of everyday life. It is therefore natural to use the
same assessment procedures for both diagnostic and treatment planning/
monitoring purposes and to assume that functional, real-world improvements
would be associated with improvement on standardized, laboratory measures.
Recent reviews of efficacy studies in this field have been critical of the capacity
of these measures to assess functional, real-world outcomes and long-term
maintenance of treatment gains. Similarly, the validity of contextualized measures
has been found to be superior to standardized neuropsychological tests in the
context of vocational planning after TBI (LeBlanc, Hayden, & Paulman, 2000).
Also criticized has been the circular reasoning involved with using the same
measures as predictor and criterion (Carney et al., 1999).

Contextualized Paradigm
Within the contextualized approach, standardized tests are used to help delineate
areas of cognitive strength and weakness, and to generate hypotheses about
potentially fruitful approaches to rehabilitation. However, standardized tests are
supplemented by situational observation (to confirm and enrich or to disconfirm
test findings) and by ongoing, contextualized hypothesis testing, designed to
systematically explore strategies, task modifications, supports, intervention
procedures, and other variables that might positively influence task performance
and learning. Test performance, if used as a measure of the effectiveness of
intervention, is supplemented by carefully planned and reliably documented
observation of the individual's in-vivo task performance (including documentation

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of the supports provided). Testing is supplemented by global markers of functional

improvement, such as maintained employment, maintained independent living,
success in school, reduction of caregiver burden, and reduction of cost for medical
care. Finally, assessment for planning context-oriented intervention must include
measures of the knowledge and support skills of the people in the everyday life of
the person with a disability.

Contextualized observation is mandated by the frequent finding that people with

TBI, particularly those with frontal lobe injury, often perform surprisingly better
or worse in everyday contexts than can be predicted from standardized test
performance (Crépeau, Scherzer, Belleville, & Desmarais, 1997; Dennis, 1991;
Dywan & Segalowitz, 1996; Eslinger & Damasio, 1985; Grattan & Eslinger, 1991;
LeBlanc et al., 2000; Lezak, 1982; Norris & Tate, 2000; Stuss & Buckle, 1992;
Varney & Menefee, 1993; Wilson, 1993). Ongoing assessment for planning
intervention is necessitated by neurologic improvement that may occur for months
or longer after some types of severe brain injury, or by the individuals'
unpredictable responses to rehabilitation and to life after the injury.

A major aspect of assessment for cognitive rehabilitation within a contextualized

paradigm is collaboration. Collaboration in assessment has several bases: (a)
Failure to collaborate with other professionals can result in over-testing and general
inefficiency in assessment. (b) Assessment can be more accurately targeted if
relevant collaborators jointly identify the questions that need to be answered and
the best procedures to answer those questions. (c) Collaborative assessments lay
the foundation for integrated, consistent, and coherent intervention. (d)
Collaboration in assessment is often an efficient training procedure for staff and
other communication partners. (e) Collaboration in assessment with the individual
with a disability is an effective procedure in relation to improving the person's self-
awareness of strengths and limitations and strategic thinking in general.

Assessment with the goal of creating and refining intervention plans also involves
thoughtful and organized testing of hypotheses. Because all behavior is multiply
determined and successful performance of real-world tasks involves complex
relationships among the individual's profile of abilities, the individual's
motivational structure, characteristics of the task and setting, and available
supports, there exists no formula for deriving the wisest intervention plan from the
results of tests alone. Decisions about specific interventions and supports are best
made on the basis of careful experimentation, based on thoughtfully formulated
hypotheses regarding specific intervention procedures and supports. It should be
noted that this approach has its drawbacks and has been the object of some criticism
by those who have expressed concern over problems with standardization and
psychometric properties inherent in this type of approach.

Executive function deficits, including weakness in the areas of self-awareness, goal

setting, and strategic thinking, are often among the most debilitating problems
following brain injury. This makes collaboration with the patient in setting goals,
testing intervention hypotheses, exploring strategic compensations, and
monitoring outcome a critical component of assessment and treatment. Finally, if
a goal of the cognitive rehabilitation program is to increase the abilities of support
people in the individual's life and improve the supports available in the individual's
environment, then objective documentation of these improvements in the

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knowledge and skills of people in everyday situations is necessary. Further,

reduction of supports needed by the individual with a disability is a critical measure
of the effectiveness of intervention.

Treatment Traditional Paradigm

Modalities or Within the traditional approach, initial emphasis is placed on decontextualized
Methods exercises designed to restore cognitive processes and skills. The goal is to eliminate
or at least reduce cognitive impairment. Computers are often used as a vehicle for
delivering cognitive exercises. The exercises themselves are typically designed to
isolate, as clearly as possible, specific components of cognition (e.g., selective
attention, organized visual perception, prospective memory, and associational
abilities) and to rebuild cognitive skills in a hierarchical manner. In the event that
compensatory behaviors or assistive equipment prove necessary, training is again
typically delivered by means of discrete and massed learning trials in clinical
settings.

Contextualized Paradigm
Within the contextualized paradigm, decontextualized cognitive exercises
designed to reduce impairment may be used if there is evidence for a positive and
generalizable outcome of such exercises. However, in many cases it may be more
effective to encourage individuals to practice functional tasks important in their
lives or to practice strategic thinking and compensatory behavior in functional
contexts (Park & Ingles, 2001). In addition, cognitive specialists employ task and
environmental modifications to facilitate the individual's success on otherwise
difficult tasks and, if possible, promote gradual restoration of function through
repeated successful performance of functional tasks with external mediation or
support (i.e., a scaffolding approach). Environmental modifications may include
training and coaching of work supervisors and other communication partners so
that they know how to provide appropriate types and amount of support and are
effective in reducing those supports as the individual regains function (i.e., fading).

Strategic thinking and behavior, that is, the effortful use of special procedures to
succeed at tasks that are cognitively challenging, are critical components of normal
cognitive functioning. Indeed, developmental cognitive psychologists highlight
the gradual evolution of strategic thinking and behavior as among the most critical
strands in normal cognitive development in childhood, and much is known about
how this aspect of development can be facilitated (Bjorklund, 1990; Bronson,
2000; Flavell, Miller, & Miller, 1993). Therefore, focusing on strategic behavior
in cognitive rehabilitation programs can and should be considered restorative. That
is, it is incorrect to assume that a strategic, compensatory focus in cognitive
rehabilitation is second best and should be considered only if restorative retraining
exercises are disappointing in their results (as is suggested by theories that sharply
distinguish between restoration and compensation).

Environmental compensations and supports provided systematically by others can

also be considered restorative interventions. Among the most effective ways to
facilitate development and restoration of cognitive functions is through
modification of functional tasks and mediated interaction with others (Vygotsky,
1978). This philosophy supports environmental and task modifications and
mediated practice of compensatory behavior as a critical approach to cognitive
development and restoration. Vygotsky's theory has led to development of

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validated programs of intervention in many fields, including educational

psychology (Brown, Campione, Weber, & McGilly, 1992; Campione & Brown,
1990), reading instruction (Palinscar & Brown, 1989), early childhood education
(Berk & Winsler, 1995; Bodrova & Leong, 1996), special education (Ashman &
Conway, 1989; Evans, 1993), and speech-language pathology (Schneider &
Watkins, 1996; Westby, 1994).

Organization of Traditional Paradigm

Treatment Within the traditional paradigm, many attempts have been made to identify
concrete treatment hierarchies within cognitive processes and systems. For
example, intervention programs often include systematic progression from
attentional processes (and subprocesses within this category such as maintaining,
shifting, and dividing attention) to perceptual processes, memory, organization,
reasoning, and other “higher” cognitive processes (Sohlberg & Mateer, 1989).
Similarly, treatment typically progresses from training exercises conducted in a
training context to systematically expanding generalization contexts. Early focus
on body structure/function-oriented exercises progresses to include activity/
participation- oriented compensatory exercises (if necessary), and finally to
context-oriented task modifications and environmental modifications (if
necessary). Treatment sequences and hierarchies of this sort are said to be useful
in organizing treatment, ensuring the individual's success with training tasks, and
building skills incrementally.

Contextualized Paradigm
Within the contextualized paradigm, these three forms of treatment hierarchy (i.e.,
intra-cognitive hierarchies, generalization hierarchies, and the body structure/
function-to-activity/participation-to context hierarchy) may be modified or even
reversed. With respect to body structure/function, activity/participation, and
context, it may be efficient in the case of people with chronic cognitive disabilties
to first modify the routines of everyday life, enabling the individual to be successful
with task modifications and possibly the support of others (context-oriented
intervention). With extensive contextualized practice of supported compensatory
behavior, the intervention may gradually shift to an activity/participation
orientation (as the individual takes increasing responsibility for strategic
compensations). Finally, with automatization of cognitive strategies, the body
structure/function limitation itself may be reduced. Thus the traditional sequence
in rehabilitation may reasonably be reversed in the case of chronic cognitive
impairment after TBI. In this respect, cognitive rehabilitation may differ from
intervention for sensory and motor impairments, in which it is often necessary to
block compensatory behaviors in order to facilitate recovery of function.

With respect to generalization, investigations of cognitive growth in children and

adults with developmental disabilities have led increasingly to the
recommendation that teaching and other forms of intervention be contextualized
from inception, with expansion outward of functional tasks and settings as mastery
is achieved (Detterman & Sternberg, 1993). This is in contrast to the common
practice of pursuing mastery in decontextualized training tasks prior to beginning
gradual transfer to functional tasks. This fundamental change in perspective was
motivated, in part, by failure to achieve generalization in treatment of persons with
developmental disabilities. The change was also motivated by increased

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recognition of the possibility that acquisition of a skill or behavior in a training

context may actually interfere with transfer to a functional context, particularly
among stimulus-bound individuals.

Finally, hierarchies within the domain of cognition itself may shift profitably from
an abstract serial ordering of cognitive processes characteristic of traditional
cognitive rehabilitation programs (e.g., from attention to perception to
organization), to hierarchies of tasks and task demands based on task difficulty
relative to the individual's specific profile of abilities and on progressions observed
in normal cognitive development. Cognitive development is characterized by
systematic growth along the following dimensions: (a) concrete to abstract
thinking; (b) context-dependent to context-independent skills; (c) real-event
routines and scripts to more abstract organizing schemes; (d) involuntary,
nonstrategic processing to controlled, strategic processing; and (e) surface to depth
(Flavell, Miller, & Miller, 1993).

Setting, Content, and Traditional Paradigm

Provider Within the traditional approach, emphasis is placed on decontextualized exercises
(e.g., content-free computer exercises), purportedly designed to facilitate broad
transfer from training tasks to functional application tasks. This approach is taken,
in part, because of the absence of specific functional content and because the
generality of the exercises is not contaminated by specific setting cues. That is, if
cognitive processes exist devoid of any specific content and can be strengthened
with exercise, it makes sense to design exercises that are as content-free as possible.
These exercises are typically offered in a clinical (inpatient or outpatient) setting.
Cognitive rehabilitation services are largely delivered by licensed rehabilitation
professionals who specialize in the service, possibly supported by trained and
supervised technicians.

Contextualized Paradigm
Within the contextualized paradigm, decontextualized exercises may be used if
there is good evidence for broad transfer of the cognitive skill to be exercised
(which is often not the case). However, emphasis is typically placed on
contextualized exercises (e.g., personally meaningful routines and activities of
everyday life; relevant social, vocational, or educational tasks) designed to
promote improved performance of personally meaningful tasks. The ultimate goal
is to facilitate transfer of these skills to increasingly broad domains of functional
tasks. Further, following acute rehabilitation, personally relevant settings (e.g.,
school, and vocational settings) and routines in those settings are often the ideal
context for cognitive rehabilitation activities.

In addition, cognitive rehabilitation services are delivered by rehabilitation

specialists, in most cases supported and augmented by people in the individual's
everyday life. That is, if rehabilitation is delivered in part through modifications
and supports in the everyday routines of life, the participants in those routines may
need considerable training and coaching from specialists if they are to play their
role effectively. Finally, because of the frequency of executive system impairment
after brain injury and the consequent need to engage patients in meaningful

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executive function tasks, it may be critical to include the patient in collaborative

decision making about self-determined and self-paced intervention activities
(Malec, 1996).

Rationale for the Impact of Intervention

Traditional The prominence of the traditional paradigm for cognitive rehabilitation can be
Paradigm explained by reference to several attractive features. First, if restorative exercises
can have the effect of substantially reducing the individual's cognitive impairment
and thereby improving functional performance in a generalizable manner, then
clinicians would be well advised to use this approach. Similarly, if training in
compensatory strategies delivered outside the routines of everyday life could result
in habituation of strategic behavior that is sufficiently flexible to apply to a wide
domain of tasks of everyday life and sufficiently durable to be maintained over
time, then again there would be no reason to challenge the traditional approach to
intervention.

Unfortunately, these assumptions have grown increasingly tenuous. Currently,

there exists at best weak support for a generalized, functional effect of process-
specific, decontextualized cognitive retraining exercises. In some areas of
cognition (e.g., declarative, explicit memory), there is general agreement that
simply exercising the process has little functional restorative effect (Schacter,
1996; Schacter & Glisky, 1986). In other areas (e.g., attention, reasoning)
controversies persist regarding the effectiveness of decontextualized, targeted
exercises. Attention training has been subjected to the most intense experimental
scrutiny. In a recent meta-analysis of attention rehabilitation, Park and Ingles
(2001) found that across the available studies, there was no statistically significant
effect of decontextualized attention training when appropriate controls were
employed in the study. In contrast, they found a robust effect when the intervention
was contextualized (e.g., driver training), although they identified only four studies
of contextualized intervention for individuals with attention deficit after brain
injury. It is worth noting that ineffective experimental designs in the field of brain
injury rehabilitation may have encouraged an inefficient approach to rehabilitation,
a point to which we return later.

Logistical Simplicity
Second, the standard organization of services within the traditional approach offers
many logistical advantages. Clinic-based intervention is certainly easier to deliver
than intervention that requires entering the everyday routines of the people being
served. Furthermore, cognitive rehabilitation packaged as a sequenced series of
exercises, using computer programs or other commercially available materials,
substantially reduces clinicians' planning time and effort. In addition, objective
documentation of performance and progress is relatively simple when the
intervention is largely delivered through well-defined exercises in clinical settings.

Not surprisingly, payers of cognitive rehabilitation services, particularly within the

managed health care market of the past several years, are more willing to reimburse
professionals for objective, measurable, time-limited activities that are part and
parcel of the traditional approach (assuming its effectiveness). Logistical
simplicities of this sort are equally attractive to researchers seeking reliable
measures of outcome. Contextualized services, in addition to being logistically

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complex, often presuppose alliances between specialists and everyday people

whose availability and competence in supporting contextualized intervention is
variable. Such alliances are often difficult to create.

Evidence From The effectiveness of massed, hierarchically organized, and apparently

Related Fields decontextualized practice in domains of intervention apparently similar to
cognitive rehabilitation may be understood by some observers as support for the
traditional approach to cognitive rehabilitation. For example, “direct instruction”
teaching methodology, based on thorough task analysis and organization of
teaching around small progressions of task difficulty and massed learning trials in
a training context, has been found to be useful in teaching many types of academic
content (Englemann & Carnine, 1991). More recently, Merzenich and colleagues
(1996) found that computer-delivered massed learning trials have been successful
in improving phonological and more general language processing in children with
neurogenic language disorders, with reported evidence of an impact on brain
structure and function.

However, a critical difference exists between teaching content (e.g., phonological

rules, word meaning, academic or vocational content) and training purported
cognitive processes devoid of any specific content (e.g., selective attention,
cognitive organization, episodic memory, and reasoning). Cognitive rehabilitation,
as traditionally conceived, takes the latter as the targets of its training efforts.
Therefore, evidence of the effectiveness of content instruction or training in any
domain may not be relevant to the question of the validity of cognitive process
retraining.

Rationale for the As emphasized in the review by Carney and colleagues (1999), most published
Contextualized studies of the effectiveness of cognitive rehabilitation have been developed within
Paradigm the traditional intervention framework. Therefore, other than a meta-analysis of
four studies (Park & Ingles, 2001), promising single-subject designs and case
reports by a handful of authors (Feeney & Ylvisaker, 1995; Von Cramon &
Matthes-von Cramon, 1994; Ylvisaker & Feeney, 1996, 1998), and one positive
randomized clinical trial with children with TBI (Braga & Campos da Paz, 2000),
little direct empirical evidence is available to support the contextualized approach
to cognitive rehabilitation for children or adults with TBI. Therefore, support for
this approach is largely derived from (a) evolving theories of cognition and
cognitive development, (b) research with related disability populations, (c) the
long-term needs of people with significant impairment, and (d) the current funding
environment with its emphasis on functional improvement with decreasing
resources for rehabilitation. The following sections address these four themes.

Cognitive Theory The history of cognitive training in fields other than brain injury rehabilitation has
frequently involved a shift from a narrow focus on training cognitive “faculties”
in the abstract to a broader and more contextualized orientation to improve specific
domains of performance that have a cognitive dimension (Mann, 1979). This shift
is consistent with the current family of theories of human cognition that highlight
context as critical to the analysis of cognitive functioning. These theories of
cognition, including mediated action theory (Wertsch, 1981), situated learning
theory (Lave, 1991), situated cognition theories of processing (Clancey, 1997),

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and apprenticeship theories of cognitive development (Rogoff, 1990), have their

historical roots in the socio-historical approach of Vygotsky and Luria, and
Dewey's pragmatic epistemology.

Context-focused theories have been supported by many studies on experts, which

tend to conclude that their special expertise lies primarily in domain-specific
knowledge, domain-specific strategies, and domain-specific motivation to be
strategic, rather than superior cognitive processing abilities in the abstract. In their
review of the literature on expertise, Meichenbaum and Biemiller (1998) suggest
that, whatever their domain, experts have a well-developed knowledge base in that
domain, are effective users of strategies in that domain (i.e., they possess more
efficient and more flexible strategies, have automatized the strategies through
practice, and tend to have environmental support for the use of strategies), and are
highly motivated to succeed in their chosen domain. These features of expert
information processors, together with the frequent finding that people with great
expertise in one domain tend to process information no better than novices in other
domains, call into question the practice of targeting general, nonspecific cognitive
processes in people with cognitive impairment after brain injury. Therefore,
current efforts to improve low-achieving students' thinking, reasoning, and
strategic approaches to academic problems tend to be embedded in meaningful
domains of content.

Furthermore, current models of cognitive processing predict the common

phenomenon of training-induced improvements on laboratory tasks or
neuropsychological tests followed by minimal transfer of cognitive skill to
functional, real-world tasks (Detterman & Sternberg, 1993). The experimental
literature in cognitive science emphasizes the relative domain specificity of
cognitive processes and skills, even in the case of adults with normal cognitive
functioning (Singley & Anderson, 1989). Minimal transfer of cognitive skill has
been observed in normal learning, based on careful experimentation as well as
experience in higher education (e.g., failure of transfer of improved writing and
reasoning skills from composition and logic classes to other academic course
work). For this reason, the contextualized training embodied in apprenticeship
programs has a long and honored history in vocational training, clinical education,
and increasingly in other domains of educational practice.

It is worth noting that the paradigm shift has largely occurred in vocational
rehabilitation. That is, the traditional model, within which formal assessment was
followed by decontextualized remediation and skill development, which in turn
was followed by job placement, has been replaced by a contextualized assessment
and supported work model that parallels the paradigm shift described in the current
paper. It is noteworthy that Chesnut and colleagues (1999) found supported
employment services to be one of the brain injury interventions most solidly upheld
by scientific evidence.

One explanation for the relative domain specificity of cognitive skill is the frequent
finding that efficiency and effectiveness of information processing are in large part
contingent on domain-specific declarative and procedural knowledge and its
organization. Indeed, cognitive neuroscientists have increasingly explicated varied
cognitive processes in terms of organized knowledge structures within which
information in a given domain is processed. At a high level of generality (e.g.,

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scripts, plans, general schemas), knowledge structures (e.g., managerial

knowledge units [MKUs]) are generally associated with frontal lobe function (e.g.,
Grafman, 1995). Damage to these knowledge structures slows information
processing; creates disorganization in thinking, planning, and social behavior;
interferes with directed and sustained attention; and causes ineffective encoding,
storage, and retrieval of information.

The emphasis on the critical relationship between domain-specific knowledge (and

its organization) and effective cognitive performance yields insight for cognitive
intervention. For example, there would seem to be value in engaging individuals
in tasks with personally relevant content with the goal of improving efficiency of
cognitive processes by means of developing appropriate knowledge structures or
MKUs. More generally, the distinction between process and content must be
questioned, with acquisition and organization of content knowledge considered in
many cases the most efficient approach to improving cognitive processing.

Evidence From Indirect experimental support for the contextualized approach has come from
Related Disability empirical studies of the effectiveness of teaching individuals with mental
Groups retardation content knowledge and functional skills in meaningful contexts
(Horner, Dunlap, & Koegel, 1988; Kavale & Forness, 1999; Koegel, Koegel, &
Dunlap, 1997). Further, in the learning disability research literature, Deshler and
Schumaker (1993) emphasized the critical importance of integrating cognitive
strategy instruction with content instruction, customizing intervention to meet a
specific student's individual and classroom needs. These authors emphasize
generalization from the earliest stages (by contextualizing the teaching),
continuing instruction until mastery is achieved (possibly requiring many months
of instruction), and engaging the student as much as possible in recognizing the
importance of personal effort and the positive effects of those efforts.

One of the well-studied interventions for individuals with ADHD, cognitive

behavior modification (CBM), is consistent with the approach we have referred to
as the contextualized paradigm for cognitive rehabilitation, if CBM is delivered in
the context of the routines of everyday life. A recent meta-analysis of
contextualized CBM for adolescents with ADHD and associated aggressive
behavior yielded a strong effect size (0.79) and solid maintenance over time
(Robinson, Smith, Miller, & Brownell, 1999).

Cross-population inferences can be controversial. However, in some cases,

nominally different clinical populations are functionally equivalent. For example,
the students with ADHD included in Robinson and colleagues' meta-analysis had
disability characterized by disinhibition and more general behavioral dyscontrol
associated with frontal lobe dysfunction and executive function impairment
(Barkley, 1997). A sizable and clinically significant subpopulation of young people
with TBI similarly evidence impulsiveness and behavioral dyscontrol, associated
with frontal lobe dysfunction and executive function impairment, as their salient
clinical characteristic. Therefore, when the two groups are given a functional
diagnosis, the cross-population inference vanishes and substantial evidence from
ADHD studies becomes applicable to this TBI subpopulation.

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Chronic Impairment
and Long-Term
Rehabilitation Needs
Following severe brain injury, even the most successful graduates of acute and
post-acute rehabilitation programs typically experience some degree of ongoing
cognitive disability. This results in the need for cognitive assessment and
rehabilitation to address chronic obstacles to success in everyday life, with
additional tools that address activity/participation limitations and environmental
supports.

To this end, the contextualized framework proposes that long-term intervention

may appropriately be directed to supportive modification of routines of everyday
activity, including educational, vocational, social, and other everyday routines.
Individuals who figure prominently in these everyday routines may become critical
allies in delivering cognitive intervention and supports. The effectiveness of this
indirect approach to intervention has been supported by investigations in other
disability fields in which the impairment is chronic and the need for intervention
long-term, including early intervention for young children with disabilities (e.g.,
Girolametto, Pearce & Weitzman, 1996; Girolametto, Weitzman, Wiigs & Pearce,
1999; Kaiser & Hemmeter, 1996), autism and developmental disabilities (e.g.,
Carr, Horner & Turnbull, et al., 1999), augmentative communication, and
supported employment for individuals with brain injury (Curl, Fraser, Cook, &
Clemmons, 1996; Wehman et al., 1993; Wehman & Kreutzer, 1990; Wehman,
West, Kregel, Sherron, & Kreutzer, 1995).

Reimbursement Private and public rehabilitation financiers have increasingly reduced resources
Trends available for rehabilitation while at the same time demanding improvements in
functional outcome. In some cases, service providers have been urged to focus
their efforts on lessening activity/participation limitations in contrast to the
traditional emphasis on eliminating or reducing the underlying impairment. The
legitimate demand of such financiers—as well as consumers—is that effectiveness
of intervention be documented in terms of meaningful improvements in the tasks
of everyday life. The cost effectiveness of a contextualized approach has been
suggested in a recent analysis of a New York State TBI Medicaid Waiver Program,
designed to support adults with cognitive and behavioral impairment in community
settings (Feeney, Ylvisaker, Rosen, & Greene, 2001). At the same time, the
demand for objective, quantitative documentation of improvement may be taken
as support for the traditional paradigm.

Recommendations
for Future Research
In this report, we have explored the recent history of cognitive rehabilitation, and
the controversies associated with that service, with the goal of suggesting that an
alternative to the traditional intervention framework may have merit based on
several theoretical and practical considerations. Both approaches are limited by
insufficient evidence, however, and much more work needs to be done to
demonstrate their effectiveness. Specifically, what is needed is increased
understanding of what constitutes effective procedures for particular patient
groups, under specific conditions, and in relation to distinct goals.

Issues Related to Treatment research characteristically begins with the examination of evidence in
Study Design related disability domains, as well as clinical case reports and single-subject
experiments. These research activities are precursors to randomized clinical trials
with large numbers of subjects. Data from such methodologically rigorous studies
is the most accepted way to establish treatment efficacy, especially in an

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atmosphere of evidence-based medicine (Sackett & Rosenberg, 1995). Random

assignment may involve designation to cognitive rehabilitation or no cognitive
rehabilitation groups, active cognitive rehabilitation versus sham cognitive
rehabilitation groups, or experimental groups using alternative approaches to
cognitive rehabilitation. Such studies should involve large numbers of patient and
control participants who have been selected to reduce bias from clinical referral
sources. They should be matched for demographic and pre-injury characteristics,
and severity of brain injury and non-central-nervous-system injuries. To date, one
randomized clinical trial comparing the two paradigms has been described in the
TBI literature, suggesting the superiority of contextualized rehabilitation for
children with TBI (Braga & Campos da Paz, 2000).

It may appear that such a scientifically rigorous protocol to measure the

effectiveness of the contextualized approach to cognitive rehabilitation may not
be feasible. One of the main tenets of this approach is that the treatment needs to
be fluid and functional, rather than rigid, and that patients participate with
clinicians in planning and monitoring the effectiveness of their treatment. It is the
research methodology that needs to be rigid, however, rather than the treatment.
Although treatment may be flexible and fluid, the science that measures such
dynamics is not. If it is the flexibility, context sensitivity, functionality, and patient-
engagement of the approach that makes the treatment successful, then a carefully
constructed study should demonstrate that it is these characteristics of the
intervention that make it successful. Good therapeutic process research can be
conducted with dismantling, constructive, or parametric strategies to discern the
individual therapeutic elements (Kazdin, 1994).

Issues Related to The treatment protocol must have sufficient flexibility to allow for (or
Selection of systematically include) participation of the patient in identifying needs, planning
Variables intervention activities, monitoring progress, selecting strategic compensations,
and the like. This component would make the intervention truly an executive
system intervention. Rigorous research methodology is compatible with
appropriate flexibility in the intervention itself. Investigation of the relative impact
of flexible treatment, which includes patient engagement in treatment decisions,
with rigid treatment protocols in which there is no such participation is itself worth
pursuing as an independent research question.

The treatment may need to be relatively long-term if the goal is to have a genuine
impact on cognitive habits. Furthermore, the treatment must explore various
aspects of context. For example, does it make a difference when the intervention
is delivered within the context of tasks meaningful to the patient? Does it make a
difference when people in the individual's everyday life are included on the
intervention team?

There are also several issues related to selection of dependent variables. Outcome
measurement must include measures that tap a variety of functional domains (e.g.,
employment, academic success, social integration, and reduction of caregiver
burden) in addition to whatever intermediate measures (e.g., standardized tests)
are selected. “Efficacy” must not be taken to mean simply that the experimental
group is statistically superior to the control group or that post-treatment scores are
statistically superior to pretreatment scores. Rather, investigators must identify
clinically meaningful and important differences in real-world functioning. Further,

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Rehabilitation of Children and Adults With Cognitive- Technical Report
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maintenance of treatment gains must be measured over substantial periods of time,

at least several months. Longitudinal investigation of treatment effects allows for
evaluation of maintenance and generalization over time.

Because of the heterogeneity embodied in diagnostic categories like “brain injury”

and “traumatic brain injury,” measures of variance are often as illuminating as
measures of central tendency. Therefore, analysis and interpretation of results
should include exploration of measures of variance and discussion of individuals
and subgroups that fall outside the central tendencies of the study samples.

With this call for more treatment outcome research, we also highlight the need for
greater funding of such research. As Malec (1996) has noted, rigorous and tightly
controlled research is expensive. Traditionally, efficacy research in the field of
cognitive rehabilitation has not been competitive with basic sciences for NIH
funding. Such funding would allow for more rigorous experimental designs and
therefore should be given high priority on research agendas.

Conclusion In an ideal world, responsible professionals make clinical decisions on the basis
of sound judgment that is supported by empirically validated clinical protocols. In
the absence of empirically validated protocols, responsible clinicians may make
decisions about intervention (whether to intervene, and if so, how) for individual
clients based on clinical necessity and informed answers to the following
questions:
• Is the proposed intervention supported by efficacy studies with populations
possessing the same disability and needs as the client?
• Is the proposed intervention supported by efficacy studies with closely related
populations (e.g., learning disabilities, developmental disabilities)?
• Is the proposed intervention supported by trial intervention with the client?
• Is the proposed intervention supported by clinical experience with members
of the client's clinical population?
• Is the proposed intervention supported by theory, including
neuropsychological, cognitive, behavioral, pedagogical, and other theories?
• Is the proposed intervention supported by negotiation with the client and
relevant stakeholders in the client's life?
• Is the proposed intervention consistent with known constraints, including
expertise of service providers, availability of support personnel, time to
complete the intervention, and adequate resources?
• Can the proposed intervention be judged to be preferable to known alternatives
—in relation to predicted functional outcome for the client—based on the
previous considerations?
• Is the proposed intervention humane, morally justifiable, and consistent with
the scope of practice and relevant licensing laws governing the provider of
services?

In this report we have urged clinicians and researchers involved in the delivery and
validation of cognitive rehabilitation for children and adults with brain injury to
examine the historical, theoretical, and empirical support for this service. We
outlined two conceptual frameworks within which the service has been understood.
Available reviews of efficacy studies conducted within the traditional framework
have failed to yield a solid empirical basis for the service. Furthermore,
developments in cognitive theory and work with related disability groups invite

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exploration of an alternative to the traditional framework. We outlined one such

alternative and called for systematic investigations of its usefulness in serving
children and adults with cognitive impairment after brain injury. Until such
investigations yield validated clinical protocols, clinicians are obligated to guide
their practice by thoughtful answers to the questions listed above.

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