Diagnosis and Therapy
Approaches for the
Speech Language Pathologist
Cognitive Functions
 Domains of Cognitive Function
1.Attention
2.Memory Processes :short and
long term
3.Verbal language
4.Categorization :Means of
incorporating new info and
organizing info in the brain
5.Abstract thought
Constantinidou, Thomas, & Best
(2004)
1.Attention
 Orienting Network
 Guides the sensory organs to relevant
locations within the environment so
that processing of information in
those locations is enhanced
 Executive Network
-Central executive” coordinates
working memory, orienting network, and
processes of the short term memory
 Alerting Network
 Ability to maintain arousal or
alertness
Orienting Network
 Attentional orienting is closely
tied to shifting the gaze of the
eyes to expand the visual field in
which the organism must
respond
 Selective, focused , sustained,
shared, shifted With brain damage this basic
skill is often affected and
impedes learning
In terms of survival in the “wild”,
this impairment may be fatal.
Executive Network
The Executive Network is
responsible for assessing the
situation, ensuring the most
important features are amplified
and selecting the most
important responses.
Prioritizing
List situations where
Executive Network is
employed in daily life:
Driving?
Planning dinner
Time schedules
Executive Network
 Flexibility
 Capacity to multitask
 Switch attention
 Organize sequences
 For Word Finding: one may alter
response selection (if you can’t
think of the word, you
sometimes use another in the
file that you can retrieve that is
like it)
Alerting Network
 Ability to maintain arousal or
alertness
 Ability to discriminate the
presence of distracters
(vigilance)
 One Cognitive therapy might
include learning to recognize
and control adverse
environmental and personal
conditions, training the
person to become resistive to
distractions
2.Memory Processes in the
Executive Network
 Memory is organized with respect to
time and contents
 Short term/working memory
 Long term memory
explicitsemantic, experiential event
Someone with damage to the Explicit
portion of the Executive Network will
be disoriented , not remember the space
or the room where they always have
therapy , and demonstrate nervous
behavior
implicit-skills and habits,
perceptual, conditioning
3.Verbal Language
 Brain injury can result in a generalized
cognitive disruptions that often affects
complex linguistic abilities
 Traditional aphasic syndromes are not
often associated with TBI
 Word finding / lexical retrieval –
associated in TBI with slower speed of
information processing along with
retrieval difficulties
4. Categorization
 Assigning objects or events
into groups
 Interrelated with other cognitive
processes
 Object recognition
 Problem solving
 Decision making
 Sustained attention tasks that
require sorting
 Learning and memory
 Categorization is critical to
problem solving in order to
consider solutions
Components of
Categorization
Recognition and Categorization of
everyday objects involves two
anatomically and functionally distinct
pathways.
Brain Injury may cause deficits in both
identification and categorization
because the two areas of the brain are
not communicating.
5. Abstract thought
 Reasoning
 Decision making and
 Problem solving are the highest
forms of cognition in what we
think of as human intelligence
 Abstract thought emerges from the
interaction of all the other
processes
 Dementia, Degenerative disorders
and TBI >reduction in abstract
thinking
Memory processes table
 Attach at the end
TBI, CHI, CVA , Progressive Aphasia , Dementia,
Developmental , Autism spectrum, CP, LD, may each be
faced with challenges:
 Attention
 Organization and categorization
difficulties
 Learning difficulties
 Memory deficits
 Information processing impairments
 Executive functioning deficits
Reasoning, decision making, problem
solving
Psycho social- anxiety and depression
Social-Communication difficulties
Receptive and Expressive Language
Patients we have known:?
Adults *
Children- different but may show cognitive
deficits during development
Approaches to Diagnosis
We obtain functional information in
a good New Client / caregiver
interview
1. Static -quantitative diagnostics:
tests one point in time/normed
 Cognitive Linguistic Quick Test
 Cognitive Abilities Screening Test
 Functional Communication Profile
 Language -Cognitive-Communication
 WAIS III-Digit Backward and Symbol
Subtest
 Boston Diagnostic Aphasia Exam-has
subtests which test cognitive functions
 Stroop Color Word Test
Note: on many of the test, especially the
WAIS III, the premorbid intellect
measures may affect the performance
Approaches to Diagnostics
 2.Qualitative: observation of behaviors
during tasks performance . Provides
info on how task is performed
 3.Dynamic assessment: not a single
packet or procedure but a model and
philosophy that :
 All people are capable of some degree of
learning (stimulus/cueing
hierarchies)
Diagnostic therapy is dynamic
assessment: the assessor actively
intervenes with the goal of intentionally
inducing changes
*2 & 3: Viewed as an addition to the other
approaches but not a substitute for
existing procedures
Differential Diagnostics
 Differential Diagnosis of Aphasia ,
Cognitive disorders and
progressive disorders, Dementias
 Conditions may co-occur
[Think of your caseload and
identify aspects of language vs.
cognitive function. How does one
effect the other?]
 The functions may be located in
different areas of the brain
 If they do not interact well =
cognitive disorders
Approaches to Therapy
What do we know about how learning and
behavior are indicators of what is going on
neurologically?
Restorative
 Skill building
 Repetition
 Stimulus/Cueing
Hierarchies
 How do our
therapies help
the client
develop
functional skills
for life?
Compensatory
 Based on the
assumption that
some abilities
may not be
restored
completely
 Develop
functional
strategies
Brain reorganization and
sprouting following injury
Damage may
cause
compression,
breakage, cell
death and lost
function
Sprouts form
Phagocytes clean
Out damaged neurons.
If the neurons are
stimulated, they
continue to be viable
for new synapse growth.
Sprouting constitutes
A reorganization of those
connections
Restorative
 Improve skills through use of exercises and
drills
 Good potential for learning
 Optimizes function through dynamic
,aggressive rehab
 Treatment may integrate multiple
functional tasks and can involve more than
one discipline
 Few environmental modifications are
required
 For CVA, mild TBI, Brain tumor, reversible
Dementia, stage 3 dementia
Restorative
• Skill Building
• Repetition
• Stimulus/cue hierarchies
• Major skill is
maintaining attention
with out distraction
and with distraction
– In a young child: attending
following simple commands
Listening to a story
initiating interaction
– In an older child or teen –
finishing a written task
– In an adult- making a grocery
list
Memory Therapy
Techniques
 Restoration/Traditional Model
 Chunking: grouping things
 Organization –Categories, semantic
meaning, similarities, visual
images(notebook of pictures)
 Rehearsal

Sequences, places, facts, situations
 Elaboration/linking

Taking what one already knows and linking it
in some way to what one wants to remember
(say out loud)
Categorization Program
Constantinidou, 2001
 A: Recognition and categorization of
common objects
Level 1:Perceptual feature training
 Different perceptual features
Level 2: same and different
Level 3 functional categorization
Level 4 Analogies
dog:puppy Cat: kitten
reserved : personable introvert:?
Level 5: abstract categorization
opposites, similarities
 B New Category learning tasks
Categorizing by 2 parameters
Compensatory
 Assumes that the client cannot recover
completely
 With caregiver/family
 Functional strategies

calendars

list making

communication notebook
 phone usage
 Verbal Routines
Compensatory
 Patient may require cueing to optimize
performance
 Provide training in those compensatory
strategies
 Alternate forms of communication
 External compensatory strategies
 Internal compensatory strategies
 For Alzheimer’s Disease, TBI,
Degenerative neurological, Dementia
stage 4+
Adaptive
 Focus of the treatment is on adaptation
of the environment and caregiver
education
 Identifies strategies to prevent further
dysfunction
 For Dementia stage 5-6
 Moderate to severe TBI
 Degenerative neurological diseases
Cognitive Functions’ Worse Enemies
 Stress and
 Vitamin B-12
Anxiety
 Depression
 Metabolic
Diseases
 Thyroid
gland,
diabetes,
organ
failures,
 alcoholism
deficiency
 Infections
 Drugs
 ADHD
 Hypothyroidism
 Aging