People With Cognitive Challenges Can Enjoy Rapid Success in Acquiring Skills and Managing Their Lives: The Exciting Breakthrough of Cognitive Orthotics

Marilyn M. Bergman, Ph.D.
MASTERY Rehabilitation Systems(TM) Inc.
105 Bala Avenue
Bala Cynwyd, PA 19004-3307
Voice/TDD/Message: (610) 664 2025; (800) 859 2828
FAX: (610) 664 1099
Internet: 75601.655@compuserve.com

Web Posted on: November 22, 1997

Effective intervention is a critical issue in the rehabilitation of people with cognitive deficits. The development of cognitive orthotics as a compensatory approach presents an important effective advance in the compendium of available interventions and strategies. Traditional interventions seek remediation through training and repetition, which too often are frustrating, inefficient and unreliable in outcome. For the person undergoing neurological recovery, as progress inevitably slows and then plateaus, conventional techniques yield fewer, less impressive results. Eventually the person is deemed to have "gone as far as he can go."

Rehabilitation literature now contains reports indicating that computer software can be designed to be an orthotic for people with brain damage.(Fowler et al, 1972; Jones & Adam, 1979; Kirsch et al, 1987; Chute et al, 1988; Bergman, 1991a, 1991b; Bergman & Gordon, 1991; Golfus & Brown, 1991; Bergman & Kemmerer, 1996). One system, Essential Steps(R), was designed to enable people with significant cognitive deficits to perform a variety of functions unassisted, and to be as self-sufficient as possible in managing their daily lives. Design was a synthesis of clinical expertise (grounded in principles from neuropsychology, learning theory, cognitive theory, and brain injury rehabilitation) with computer technology. This cognitive orthotic is an assistive compensatory aid which supports "weak or ineffective" cognitive functions. It provides the structure, organization, simplicity, sequencing and consistent cueing that people with significant cognitive deficits can not access spontaneously and automatically. The design also ensures that information is safeguarded and readily accessible. And all this is done without burdening weakened memory functions. People with cognitive deficits are typically slow to learn, but with the cognitive orthotic they appear to demonstrate rapid acquisition of the ability to use it successfully. Rapid skill acquisition is a revolutionary notion for this population. It is possible because specific cognitive orthotic design features promote errorless learning. engage procedural memory, and promote training transfer (Bergman & Gordon, 1992b; Bergman, 1997). To elaborate, insofar as first learning is most robust learning, when first use is errorless then skill acquisition is powerful and efficient. Thus the common inefficiencies of incorrect or insufficient learning, unlearning and relearning are eliminated. Procedural memory, the acquisition of skills through action rather than through instruction, remains a resource for people with cognitive deficits. By actively engaging the cognitive orthotic, the user quickly masters the procedures of this system. Finally, consistency of design across activities of varied content facilitates generalization. An unselected series of fiftyfour (54) people with deficits from neurologic and developmental etiologies (e.g., traumatic brain injury, stroke, aneurysm, brain tumor, anoxia, electrocution, toxic exposure, encephalitis, attention deficit disorder, mild mental retardation, etc.) demonstrated rapid skill acquisition in individual trials (see Figure 1) with Essential Steps(R). Mastery, defined as the "successful, unassisted, reliable completion of a targeted task," (Bergman, 1997) was the goal in each trial. Typically people mastered a journal within minutes (95%, n=54 tested subjects), and then independently proceeded to make directory entries(100%, n=16 tested subjects) log telephone calls (91%, n=41 tested subjects), schedule appointments (93%, n=46 tested subjects), make bank entries (savings 98%, n=44 tested subjects; checking 86%, n=37 tested subjects) and complete a job task following a guided sequence (100%, n=4 tested subjects).

In this current series, a large proportion of people with diverse demographic and descriptive factors, and varied cognitive impairments stemming from diverse etiologies, are able to master the Essential Steps(R) cognitive orthotic system. The success of people as many as 20 years following onset, including severe traumatic brain injury, is particularly noteworthy. Those few who were unsuccessful in these cognitive orthotic trials are distinguished by a constellation of five or more specific deficiencies: low intellectual functioning, Rancho Los Amigos level of VI or below, disorientation, serious memory impairment, sensory/perceptual deficit and impaired reasoning and judgment.

The following incidental remarks made while undergoing the Essential Steps(R) cognitive orthotic trial (person 1) or just upon completing a trial (persons 2 and 3) are enlightening:

Everything I've needed so far has been right there on the screen. That makes it really easy. I'm used to systems where you have to remember so much stuff..., and it's like you've gotta be kidding me. (Person 1)

This is the first time in two years [since sustaining injury] that I feel successful. (Person 2)

I got it. It's almost easy. (Person 3)

Clearly the trial provided opportunity for the experience of success and self-satisfaction, obvious secondary benefits of rapid mastery.

Successful long term integration of the Essential Steps(R) cognitive orthotic into daily living activities at home, school and work, is illustrated with five people. Longest consistent use is 10 years (by JM, apparently the longest and most extensive user of cognitive orthotics reported in the literature). The remaining four people show consistent usage of their systems for between three and six years.

Incorporation of a cognitive orthotic system as a means for effective self management, to the fullest extent responsibly possible, is a major objective of this compensatory approach. The 'fullest extent responsibly possible' will vary from individual to individual, depending on the type and severity of physical and cognitive deficits. The degree of self-sufficiency will reflect the ecological relevance of selected tasks and the precision of the orthotic design for that individual user. Furthermore, for a given person the Essential Steps(R) cognitive orthotic system can evolve dynamically, based on reassessment of needs, goals and objectives.

Over time, individuals appear to develop patterns of use and strategies with the cognitive orthotic which are unique, creative and specific to their needs (Bergman & Gordon, 1992). To illustrate, consider the alternative strategies developed using the Telephone Log by two different users with different needs. One woman reviews her telephone log prior to making call, to be current on the content of her most recent conversation with the person she is calling and appear more competent in her relationships. Another user, a socially inexperienced and uncertain young man, outlines a conversation into the telephone log prior to calling a girl for a date.

Benefits of a cognitive orthotic like the Essential Steps(R) compensatory system extend beyond the accomplishment of specific tasks to include cost effectiveness (through reduction of conventional assistance, such as residential living), resumption of work and productivity, diminished frustration, anxiety and depression in the family as well as the user, improved behavioral functioning, increased self- sufficiency and enhanced self-esteem. Clearly cognitive orthotics can foster rapid, easy acquisition of practical relevant tasks, thereby enabling users to enjoy independent successes in their daily lives.

References

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Bergman, MM. The necessity of a clinical perspective in the design of computer prostheses. J Head Trauma Rehabil. 1991b;6(2):100-104.

Bergman, MM & Gordon, GE. A Computer-Orthotic System to Support Multiple Functions for an Individual With Traumatic Brain Injury (TBI). Journal of Clinical and Experimental Neuropsychology 1991;13(1), 105.

Bergman, MM & Gordon, GE. Customization of a Multiple Function Computer Orthotic system for Two Individuals with Differing Patterns of Chronic Traumatic Brain Injury (TBI). Journal of Clinical and Experimental Neuropsychology 1992a;14(1), 76.

Bergman, MM & Gordon, GE. A Computer Orthotic: Practical Application of Errorless Learning and Procedural Memory (Poster Presentation). Cognitive Rehabilitation, Community Integration Through Scientifically Based Practice, Richmond, Virginia, 1992b.

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