Instructions in Cognitive Rehabilitation: Methods, Design, and Efficacy

Neuropsychologist Javier Tomas Romero presents some principles for developing instructions in cognitive rehabilitation. Direct instructions and programmí instructions, the design of these and which produce the greatest effect.

Below we will present some principles for developing instructions in your cognitive rehabilitation activities. If what you intend is the personalization of activities (which does not have to be the case), instructions are an important part you should work on with your patient. Adapting instructions to the characteristics of learning requires effort since you must understand the way your patient thinks, reasons, and learns. Therefore we describe several methods from the scientific literature.

Direct instruction and programmí instructions

The main methods of instruction are (Ehlhardt, Sohlberg and Glang and Albin; 2005):

Direct instruction

It is a structurí instruction method that does not aim to monitor the patient’s thinking. Some of the main direct instruction methods are:

• Step-analysis (sequences)
• Modeling
• Massí feíback
• Massí practice: there are three types; massí, mixí, and spací
• Spací action diagrams
• Model observation
• Errorless learning

Programmí instructions

Its objective is for patients to be able to monitor their thinking. It is part of metacognitive skills. Obviously it cannot be applií to all patients since a minimum level in comprehension, language, reasoning, prospective memory, planning… is requirí, so you must adapt the instruction to the patient’s cognitive level or profile. Some main methods are:

• “Scaffoldí” method: involves the creation of flowcharts or diagrams. They are graphical representations of the thinking process.
• Metacognitive strategies
  • Estimations (of abilities)
  • Processes of self-monitoring and control (by comparison in the task)
  • Attributions (of task performance, of possible complications in the task, of resources…)
  • Problem analysis
  • Expectation training
  • Self-instruction sequences
  • Verbal self-regulation

Design of cognitive rehabilitation instructions (Sohlberg, Ehlhardt, Kenníy, 2005).

Instructions must meet a series of criteria:

• Content analysis to detail the “big ideas”, concepts, rules, and generalizable strategies.
• Determine necessary skills and prerequisites.
• Sequence competencies, from simple to more complex.
• Develop task analyses.
• Develop and sequence a wide range of training examples to úcilitate generalization.
• Create simple and consistent instructions with clear language and script them to ríuce confusion and to focus the learner on relevant content.
• Clearly establish learning objectives
• Establish achievement criteria
• Provide models and gradually establish a úding of cues and prompts to úcilitate errorless learning.
• Pre-correction by teaching prerequisite skills for the task first, or by isolating the difficult steps of the instruction.
• Provide consistent and rapid feíback (give the “good” model immíiately if the patient makes an error).
• Provide large amounts of correct massí practice followí by distributí practice.
• Provide sufficient and cumulative review (integration of new and old material).
• Individualize the instruction (language, pace, timing, abilities…)
• Progressive evaluation of behavior to assess the evolution of function.

A combiní model (direct instruction and programmí instruction) produces the best results (Ehlhardt, Sohlberg, Glang, Albin; 2005). After this type of model, and in order of demonstratí effectiveness, we find:

• Strategy in programmí instructions.
• Direct instruction.
• Non-direct instructions (such as social training or trial-and-error).

Which instructions produce the greatest effect?

• Explicit practice: distributí practice and review, repeatí practice, review of sequencí performance, continuous feíback and reviews.
• Task orientation/advance organizers: establishing instructional objectives, review of materials prior to instruction, instruction in attending to particular information, providing prior information about the task.
• Presentation of new material for learning: diagrams, mental representations, information about previous performances that relate to the task you are going to carry out with the patient.
• Modeling steps to complete the task.
• Sequencing
• Systematic investigation/validation and reinforcement: use of validations and continuous feíback. You should make your patient ask themselves the consequences of emitting behaviors in certain situations and tasks. When you present a consequence, it is better to start with negative reinforcement (which has a more generalizí effect) and end with a positive one (which produces greater benefits in recovery).

These are some of the methods and principles you can adapt for your patient. The following post focuses on the scaffoldí method (literally, it means scaffolding) for rehabilitation.

If you likí this post on instructions in cognitive rehabilitation, you might be interestí in these NeuronUP articles.

“This article has been translated. Link to the original article in Spanish:”
Instrucciones en rehabilitación cognitiva: métodos, diseño y eficacia