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EMPIRICAL EVIDENCE: OTHER COGNITIVE DOMAINS
There is some evidence for the efficacy of interventions in the rehabilitation
of attention deficits (Ben-Yishay, Piasetsky, & Rattok, 1987; Sohlberg
& Mateer, 1989) and visual-perceptual disorders, (Gianutsos & Matheson,
1987; Gordon et al., 1985; Ruff et al., 1989). Treatments that may involve
some computer assisted procedures are also under investigation to improve
reasoning and judgement (Goldstein & Levin, 1987; Prigatano, 1986).
Clinical investigators reporting such findings, however, typically note
a number of hard-to-control methodological shortcomings in this research.
These include (a) lack of appropriate control groups, (b) lack of methods
for distinguishing the effects of the computerized intervention from other
ongoing rehabilitation the patient is receiving, (c) lack of methods for
controlling the influence of spontaneous recovery, (d) difficulty in evaluating
the effect of the intervention in daily life once training has ceased,
(e) over utilization of "select" patients or candidates who have high prospects
for success, and (f) insufficient acknowledgment of the need for controlling
for the Hawthorne effect.
Sohlberg and Mateer (1989) and Malec (1986) have pointed out
the importance of regarding cognitive rehabilitation as a set of different
procedures used to improve personal functions related to different cognitive
domains. Principles for training may be significantly different as applied
to different cognitive skills. For instance, although it is now clear that
memory cannot be improved by repetitive drills or massed practice as previously
discussed, practice may contribute to gains in attentional capacities (Sohlberg
& Mateer. 1989). Although the disappointing research literature in
memory rehabilitation efforts suggests the need for a cautious approach
to evaluating efficacy studies in other cognitive domains (Cicerone &
Tupper, 1986; Gordon, Hibbard, & Krcutzer, 1989), the clinical and
experimental literature relevant to rehabilitation in these other cognitive
domains suggests that interventions being developed hold more promise and
should be vigorously and rigorously pursued (Lynch, 1988; Rimmele &
Hester, 1987).
RESOLUTIONS:
Ideally, cognitive rehabilitation techniques and procedures should be empirically validated in the manner suggested by Paul (1969) who observes that the ultimate empirical validation question is... What treatment, by whom, is most effective for this individual, with what specific problem, under which set of circumstances, and how does it come about? (P. 62). Until such time as Paul s very demanding definition can be achieved, the following guidelines are suggested.
2.1 In view of the absence of evidence for the efficacy of memory drills for the purpose of generalized memory improvement, there appears to be no empirical justification for clinical use of computers to these ends.
2.2 The use of computers to teach mnemonic strategies, as external aids, and as supports for employment appears to have more realistic and promising prospects, although much more research is needed before confident deployment in the clinical realm is justified (Kurlychek & Levin,1987).
2.3 The efficacy of cognitive rehabilitation techniques should be evaluated in terms of the specific cognitive domains under study. Thus, negative findings in the domain of memory should not be unfairly generalized to potentially more remediable deficits in other areas (e.g., visual-perceptual disorders, attention). This implies that comprehensive neuropsychological examinations employing reliable and valid tests at strategic points independent of training content are an essential component of such programs of development. Standardized psychological and neuropsychological tests should not be utilized in cognitive remediation exercises or therapy.
2.4 Results of investigations based upon less than ideal research designs should not be subjected to pejorative dismissal if the limitations of such designs are explicitly stated by the investigator and appropriately modest conclusions are offered. Many clinical settings and difficult clinical questions may not lend themselves to rigorous experimental research but such considerations should not limit continuing investigation using other scientific methodologies (e.g., single case design, systematic clinical observations). At the same time, reports of efficacy based upon uncontrolled case or cohort studies, testimonials, or anecdotal findings are unacceptable evidence of efficacy.
2.5 The Discussion and Resolutions offered under Issue 2 should be reviewed on a regular basis (e.g., every 5 years) and updated as required, based upon new research findings.
ISSUE 3: CONSUMER PROTECTION, RISK/BENEFIT ANALYSIS
As discussed thus far, clinical and research experience in cognitive
rehabilitation warrants some degree of optimism about the clinical utility
and efficacy of these procedures. Nonetheless, inherent risks appear to
be present that must also be considered.
One potential risk of cognitive rehabilitation is that false
hopes may be raised, and denial of disability may be reinforced, for the
cognitively impaired individual and his or her family. This can occur because
small objective gains in skill with a given training exercise may follow
from long hours of interaction with the training task. These small gains
become the straw of hope at which the disabled person and family grasp
as evidence that further significant improvement will be forthcoming, even
when all other evidence indicates future recovery of cognitive ability
will be minimal.
A second risk is that the development of an isolated or task-specific
skill may serve as false evidence of general competency for the cognitively
impaired individual and the family. In this way an inaccurate perception
of the disabled individual emerges; this can interfere with rehabilitation
efforts and recommendations for safe conduct. Generalization must be demonstrated
and not merely presumed.
Thirdly, focusing efforts and time in the use of cognitive rehabilitation
software runs the risk of, diverting attention from more problematic concerns
which potentially may be more directly remediable. These would include
family problems, social and vocational adjustment issues, emotional disorders,
and financial problems. Financial problems can, of course, be exacerbated
by professional charges resulting from the interminable and inappropriate
employment of cognitive rehabilitation software in treatment.
Fourth, significant time spent working with cognitive rehabilitation
software may perpetuate social isolation of the cognitively disabled individual.
Distraction may be reduced through the utilization of the computer-patient
interface in some cases, but this must be individually assessed.
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