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DELHI PSYCHIATRY JOURNAL Vol. 12 No.1 APRIL 2009

Original Article
Efficacy of Cognitive Retraining
Techniques in Children with Learning Disability
Shahzadi Malhotra*, G. Rajender**, Vibha Sharma*, T.B.Singh*
*Department of Clinical Psychology, Institute of Human Behaviour and Allied Sciences (IHBAS),
Dilshad Garden,Delhi and **Department of Psychiatry, UCMS & G.T.B. Hospital, Dilshad Garden, Delhi,
University of Delhi

Abstract
Background :Cognitive Retraining(CR) is known to help in reattainment of cognitive abilities
following brain injury.Due to high cerebral plasticity in children,CR can perhaps also be used
to ameliorate known cognitive deficits in children with learning disability. Objectives: To study
the efficacy of cognitive retraining techniques for enhancing cognitive skills and scholastic
performance in children with learning disability. Sample & Methods: Pre and Post experimental
design study was carried out with thirty children(between eight to ten years of age), with
diagnosis of mixed disorder of scholastic skills(ICD-10). Each subject was given 36 hours of
manualized CR package over 18weeks, consisting of activities for sustained attention,visuospatial
skills,visual memory;and verbal learning and memory.Pre and post intervention assessment;
was done using NIMHANS Index for Specific Learning Disability,Grade Level Assessment
Device(GLAD) and Rey’s Auditory Verbal Learning Test(AVLT).SPSS version12.0 was used for
descriptive and analytical statistical analysis. Results:Highly significant improvement was noted
in total verbal learning, delayed verbal recall,visuo-spatial skills and mathematics(p>0.01).Also,
there was significant improvement in sustained attention(time taken and errors),visual memory
and immediate verbal recall(p>0.05). Conclusion:Manualized cognitive retraining over thirty
six hours can help to partially remediate cognitive deficits in children with learning disability
and improve their scholastic performance. The findings have implications for future educational
curricula aiming at improved academic performance stemming from an enhanced skill base
rather than from just educational based interventions.
Keywords: Cognitive retraining,Learning disability

Introduction trained on unstructured tasks can, when retrained

Cognitive retraining (CR) is defined as “thera-
peutic modalities which improve a brain injured
person’s higher cerebral functioning or help the
patient to better understand the nature of those
difficulties while teaching him/her methods of
compensation”1. It rests on the principles of cerebral
plasticity and aims to bolster specific cognitive
capacities that ar e weak and also to teach
compensatory strategies 2,3. Early connectionist
research4,5 demonstrated that simple networks
100 Delhi Psychiatry Journal 2009; 12:(1) © Delhi Psychiatric Society
after damage, exhibit rapid recovery on treated
items and generalization to untreated items. The
latest researches in functional mapping of the
human brain have shown that the brain has the
capacity to function through different pathways
after practice or learning a task. Cognitive retraining
uses this potential of the brain to change and adapt
to help restore the lost functions.
Cognitive retraining is used primarily those
who have suffered from a traumatic brain injury (a
APRIL 2009
stroke, tumor, or a head injury). These methods
typically involve massed practice and drill
approaches, along with other psychologically based
intervention methods. The two key elements of any
cognitive retraining programme are:- repetition to
make the skill automatic, and appropriate reinforce-
ment. The neuro-cognitive domains which are
considered for retraining include- arousal and
orientation, attention and concentration, memory,
visual and spatial perceptual abilities, language and
verbal skills, executive functions (reasoning,
planning, organization, problem solving), life skills
and social skills. Each identified skill is retrained
using sequentially increasing graded practice of
activities using the method of saturation cueing
followed by generalization. It makes use of the
person’s stronger capacities to bolster the weaker
ones. The process continues with diminishing
degrees of assistance.
A number of cognitive retraining methods have
been utilized, most of which use specially designed
computer software, and are called computer assisted
cognitive rehabilitation (CACR). The empirical
evidence for CACR seems to indicate a potential
for improving cognitive function6. The widespread
use of computer assisted cognitive retraining
procedures is largely because the computers allow
accurate timing of stimulus presentation. Further,
it is possible to regulate time of stimulus presenta-
tion based on individual’s performance. However,
the drawback of these programmes is their rigidity
which may be incongruent with patient’s need. The
floor and ceiling level along with the task content
are relatively fixed. Further, the cost of cognitive
retraining soft wares is another major limitation.
Manualized retraining programmes overcome these
limitations though at the cost of precision. However,
found no difference in outcome between computer
assisted and manualized cognitive retraining
programs which are more suited in Indian context7.
Neuropsychological studies, structural and
functional imaging as well as electrophysiological
studies provide evidence for central nervous system
dysfunction in learning disabilities 8,9,10 .The
literature on cognitive retraining strongly purports
that cognitive retraining is an effective therapeutic
module for enhancing cognitive skills. Considering
high cerebral plasticity in children and the relation
between cognitive skills and academic performance,
Delhi Psychiatry Journal 2009; 12:(1) © Delhi Psychiatric Society
DELHI PSYCHIATRY JOURNAL Vol. 12 No.1
if one uses cognitive retraining techniques with
them ,it is highly likely that these techniques would
enhance the cognitive functioning of children and
thus, potentially enhance their academic perfor-
mance. This would further have a profound impact
on education. In addition, improved academic
performance stemming from an enhanced skill base
(e.g., improved attentional skills, improved
deductive and inductive reasoning, ability to
manipulate numbers and concepts, etc.) rather than
from just educational based interventions would
appear a more desirable avenue as the child would
actually “own” the skills to acquire knowledge and
prevent “Matthew effect”.11
There are very few studies which have studied
the effects of cognitive retraining interventions in
children with learning disability12,13.These studies
have restricted to retraining in one or two cognitive
domains. Most Indian studies have restricted their
interests to psychosocial concomitants of learning
disability14,15,16. There are almost no reported Indian
studies which have studied the above effects of CR
in learning disorder. This study is an attempt in this
direction.
Aims And Objectives
To study the efficacy of cognitive retraining
techniques for enhancing cognitive skills and
scholastic performance in children with learning
disability.
Material and Methods
Sample:
A pre and post experimental design study was
carried out with a sample of 30 children with
diagnosis of Mixed Disorder of Scholastic Skills
(ICD-10) were recruited. These children between
ages 6 to 10 years were studying in English medium
schools in Delhi in Grade 1st to 4th and were
reported to be having difficulties in school perfor-
mance. The diagnosis was confirmed using
psychometric assessments. All children in the
sample had average level of intellectual function-
ing, were attending school regularly and without
any study breaks. Children having any physical
disability, subnormal level of intellectual function-
ing, any sensory impairments, children from single
parent families or those having any other
developmental disorder other than lear ning
101
DELHI PSYCHIATRY JOURNAL Vol. 12 No.1
disability / any other neurological / psychiatric / or
any other major medical illness were excluded from
the study.
Tools:
These children were assessed using the
following:
• NIMHANS Index for Specific Learning
Disability: 17 comprises of Malin’s
Intelligence Scale for Indian Children
(MISIC), Digit Vigilance Test, Bender
Gestalt Test, Test of Visuo-Motor Integra-
tion, Auditory Memory Test, Benton Visual
Retention Test along with tests of Academic
Performance that include reading, writing,
arithmetic, spelling and comprehension.
For the present study, the Tests for
Academic Performance of this battery were
replaced by GLAD.
• Grade Level Assessment Device (GLAD)
for Children with Learning Problems in
Schools18 to assess scholastic performance.
The GLAD assesses the level of academic
performance in three basic subjects viz.
Hindi, English and Mathematics, in primary
school children while systematically
making an observation of the processing
pattern in the child. The test- retest
reliability of GLAD ranges from 0.68 for
Grade IV to 0.99 for grade III. Its Criterion
validity ranges from 0.74 to 0.89.
For assessment of targeted cognitive skills at
pre intervention and post intervention, the following
tests of the NIMHANS SLD Index were utilized:
 Digit Vigilance Test 19 was used for
assessment of sustained attention. This test
is also a measure of accurate visual scann-
ing and activation and inhibition of a rapid
response. The test consists of numbers 1 to
9 randomly ordered and placed in 50 rows
on a page having 30 digits per row. The
subject has to focus on target digits amongst
other distracter digits. The test gives two
scores (a) the time taken to complete the
test and (b) Error Score-Sum total of the
number of omissions and the number of
commissions.
 Block Design Test20 for assessment of
visuo-constructive abilities. The block
102 Delhi Psychiatry Journal 2009; 12:(1) © Delhi Psychiatric Society
APRIL 2009
design test consists of 9 blocks (cubes) each
with two red sides, two white sides and two
sides-half red and half white-divided
diagonally. The block design test has a test
retest reliability of 0.77 and split half
reliability of 0.87.
 Benton Visual Retention Test21 to assess
visual memory and visual perception. The
test provides a clinical and research
instrument with which to assess visual
perception, visual memory, and visuo
constructive abilities. Interscorer agree-
ment with respect to total scores on the
BVRT Administration A is approx 0.94.
• Indian Adaptation of Rey’s Auditory
Verbal Learning Test22 was used to
measure verbal memory. The test is an
individually administered test and gives a
measure of immediate memory, acquisition
of new learning, retention, primacy, and
recency effects, susceptibility to proactive
and retroactive interference. This test has
been found to be sensitive to the defects of
specific, clinically relevant components of
the process of verbal learning and memory.
This test has shown moderate test-retest
reliability over one year interval. Most
reliable measures are total number of words
learned over the five learning trials (r=
0.77). RAVLT correlates moderately well
with other measures such as the California
Verbal Learning Test.
Intervention Techniques Used
Activities in areas of attention, memory and
visuo-spatial abilities were adapted from various
cognitive r ehabilitation therapy software
programmes like PSCogRehab95, Challenge of the
Mind23 and used in manualized forms. Activities
used for attention involved both visual and auditory
modality and involved various adaptations of
cancellation tasks, vigilance tasks, discrimination
in the presence of distr acters, continuous
performance tasks, scanning tasks, and mazes.
Activities that targeted memory again involved both
auditory and visual modalities. These activities
included various verbal recall tasks, with increasing
level of complexity, Chinese whispers, design
recall, pattern recall, sequential verbal recall, visual
APRIL 2009 DELHI PSYCHIATRY JOURNAL Vol. 12 No.1

spatial recall and encoding activities. For enhancing
visuo spatial skills the activities included visual
copying tasks, various levels of substitution tasks,
spatial grids and sequencing activities.
Procedure
Children and parents were educated about the
nature and procedure of the study. The children were
enrolled for the study after obtaining parental
consent. All the activities that were to be used in
order of administration, including each program’s
description, mater ial requirements, set up,
instructions to students, response inputs, were
compiled. The first few sessions were devoted to
baseline assessments of children. All the baseline
assessments were done individually. After the pre
intervention assessments, the participants began the
retraining sessions, which were to be administered
twice a week, over eighteen weeks. Of these 36
sessions, 20 were individual sessions while 16 were
group sessions. Each session lasted for one hour.
Unlike cognitive retraining with brain injured
patients, the students were moved on to the next
lesson regardless of mastery of goals on the lesson.
However, high scores obtained by individual
students were appreciated during sessions where
participants could see them as reinforcement. After
the completion of the 36-lesson program, all the
tests were re-administered.
Analysis
The data thus collected following the above
design and procedure was interpreted using mean
and standard deviation and compared through t-test
using SPSS version 12.0.
Results
The mean age of the sample was 8.2 years (SD
0.68). The majority of the sample comprised of boys
and the mean number of educational years for the
sample was 5.2 years (SD= 0.86). Tables 1 and 2
show the mean and SD for pre intervention and post
intervention conditions along with t- values.
Table 1 shows the pre and post intervention
mean scores for the sample along with the obtained
t- values for all the cognitive domains. The table
reveals that the t-values were significant for
attention (both time taken and errors), visual
memory, and immediate verbal recall (p <0.05).
The values were highly significant (p <0.01) for
delayed recall, total learning and visuo spatial skills.
Further, the study of the mean scores reveals that
the sample performed better on all the targeted
cognitive skills in post intervention condition
The scholastic performance of children- both
pre and post intervention and the t-values thus

TABLE 1 – Pre & Post Intervention Comparison of Cognitive Skills

Pre Post
Cognitive Skills Mean S.D Mean S.D t-value
Attention(Time Taken) 8.9 2.11 5.2 1.03 3.555*
Attention(Error Score) 20.2 4.30 13.0 1.99 2.079*
VisualMemory 4.2 0.90 7.6 2.07 2.470*
ImmediateVerbal Recall 43.0 7.50 69.0 12.90 2.067*
DelayedRecall 32.0 6.80 62.0 5.20 5.720**
TotalLearning 50.0 5.70 76.0 3.60 3.200**
VisuoSpatial skills 86.0 3.4 106.5 13.40 6.079**
*p < 0.05, **p < 0.01

Table2- Pre & Post Intervention Comparison of Scholastic Skills

Subject Pre Mean S.D Post Mean S.D t-value
English 60.8 8.08 68.0 7.38 1.440
Hindi 63.2 5.16 65.6 6.34 1.662
Mathematics 52.8 9.66 69.4 4.44 3.801**
*p < 0.05, **p < 0.01
Delhi Psychiatry Journal 2009; 12:(1) © Delhi Psychiatric Society 103
DELHI PSYCHIATRY JOURNAL Vol. 12 No.1
obtained by their comparison are shown in Table
2.. The obtained t-values were found to be highly
significant for Mathematics (p<0.01) but were not
significant for Hindi and English. In addition
to the t-values, considering the pre and post
intervention mean scores it is implied that post
intervention, study group has shown improvement
on Mathematics.
Discussion
Cognitive Retraining techniques (CRT) have
been reported to produce improvement in patients
of traumatic brain injury24. Also CRT has been used
with patients of schizophrenia25, epilepsy 26, and
substance abuse27 and have been found to be useful.
The present study was the first of its kind in India
in which efficacy of CRT was studied in children
with learning disability and its impact on school
performance was assessed.
In the recent years, the children with Specific
Developmental Disorder of Scholastic Skills have
been implicated to have impairment in neuro-
biological pathways. For example, in dyslexia, the
functional imaging studies have implicated the
anterior network (inferior frontal gyrus) and the two
posterior networks of parieto temporal (word
analysis) and the visual word form area (occipito
temporal) 28. The present authors have studied
children with mixed disorder of scholastic skills as
they are expected to have impairment in many
neurocognitive domains and associated neuro-
biological pathways, which were specifically
targeted using CRT. There is evidence from studies
that impairment in cognitive and scholastic skills
lead to impairment in scholastic performance. For
instance, it has been reported that attention and
memory to play a crucial role in information
processing29 . A strong association has been
reported among reading speed and accuracy, teacher
rated scholastic assessment; attention span and
visual reaction time.
Hence probably by targeting these cognitive
domains using CRT one can enhance the scholastic
performance of these children and can also prevent
Matthew effect 11. In this study subjects were given
36 sessions of manualized cognitive retraining over
a period of 18 weeks and were then followed up
after a period of 6 months. This manualized
cognitive retraining module developed for the study
104 Delhi Psychiatry Journal 2008; 12:(1) © Delhi Psychiatric Society
APRIL 2009
largely included activities in the basic cognitive
skills of attention, visual memory, verbal memory
and visuospatial skills. Based on Piaget’s Cognitive
Development Theory these activities with graded
difficulty level were included and were associated
with all the three levels: concrete, semi concrete
and abstract.
From the results section, it is observed that
cognitive retraining produced significant enhance-
ment in the targeted cognitive skills of children
(Table 1). With respect to attention, there is a
significant reduction in the time taken to complete
the task and number of errors committed. It was
also observed that there was a reduction in both the
number of omissions (indicative of visual scanning)
as well as commissions(indicator of response
inhibition). Thus, with retraining both visual
scanning and response inhibition improved. Gains
in performance on test of visual memory and visuo
spatial skills have also been observed. There has
been significant enhancement in all three measured
aspects of verbal memory. This implies that either
the consolidation process has improved or/ and
interference processes have decreased with this
training package. Bracy et al. used computerized
cognitive skills training program which focused on
training attentional, executive, visuospatial and
problem solving skills in 12 to 14 year old children
and reported a significant increase in intellectual
functioning (p< .01)30. Also, studies have reported
significant improvement in attention after 10
training sessions by using Computer Assisted
Instruction (CAI) approach for enhancing attention
in elementary school children31. Review of these
Cognitive Retraining Therapies32 have stressed on
techniques that are geared toward improving visual
scanning and ‘retraining’ of patients to attend to
the neglected field as the mainstay of these
therapies.
Further, in the post intervention condition, there
have been significant improvements in children’s
performance on mathematics. However, there have
been no significant gains in the two language
subjects (Table 2). It is known that in addition to
deficits in cognitive skills, children with learning
disability also have difficulty in understanding
phonetic sounds and sound blending which play a
very important role in r eading and writing
processes, and are the building blocks of languages
APRIL 2009
like Hindi and English. There are also reported
deficits in the central auditory processing in
children with learning disability. Since in the
present study, the intervention was solely aimed at
enhancing basic cognitive skills of attention,
memory and visuo spatial skills , and did not target
either the enhancement of understanding and use
of phonetics or the central auditory processing and
this partially explains the reason for learning
disability children not showing any significant
improvement in these two language subjects which
are highly dependent on the phonetic understanding
and usage as well as auditory processing. Also
Bryant reported that visual-spatial problems may
interfere with a child’s ability to per form
mathematical problems correctly including
misalignment of numbers in columns, difficulties
with place value etc33. Thus, mathematical skills
which largely involve the use of attention and visuo
spatial functions (which were targeted in the study),
the group has shown significant improvement.
The improvements in cognitive skills can be
explained by long term potentiation in various
circuits involved in different cognitive domains, like
right fronto striatal system for attention etc. Recent
functional MRI studies34 have identified a subgroup
of severe dyslexics PPR ( Persistently Poor Readers,
who remain poor readers at 9th Grade) who have
difficulties which are influenced by poorer training
of pre academic skills despite having less functional
deficits on MRI. CR in PPR on the domains of
verbal memory have shown to improve outcomes.
As the research identifies subgroups of patients
within the various categories of the specific
disorders of scholastic skills, more precise CR
interventions targeting specific cognitive domains
will become an important modality of treatment in
future.
Studies also report that children with mixed
disorder of scholastic skills develop compensatory
mechanism (like using anterior system pathways
bilaterally) by using other brain pathways ,very
much similar to CR, but this happens by late
adolescence35. Probably by early intervention in
these children using CR one can enhance and fasten
this process of compensation helping in acquiring
better academic skills at an early and appropriate
age and prevent Matthew effect.
Delhi Psychiatry Journal 2009; 12:(1) © Delhi Psychiatric Society
DELHI PSYCHIATRY JOURNAL Vol. 12 No.1
Conclusion
Manualized cognitive retraining over thirty six
hours can help to partially remediate cognitive
deficits in children with learning disability and
improve their scholastic performance.The findings
have implications for future educational curricula
aiming at improved academic performance
stemming from an enhanced skill base rather than
from just educational based interventions.
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