CLINICAL OF INTERVENTION OF INTERVENTION

EDITED BY

BARBARA P. UZZELL Hospital of the University ofPennsylvania YIGALGROSS Bar-Ban University

MARTINUS NIJHOFF PUBLISHING A MEMBER OF THE KLUWER ACADEMIC PUBLISHERS GROUP BOSTON DORDRECHT LANCASTER © 1986 by Martinus Nijhoff Publishing.Publishing, Boston. All rights reserved. No part of this publication may be reproduced,reproduced. stored in a retrieval system,system. or tr.lnsmittedtrdlnsmitted in any form or by any means,means. mechanical.mechanical, photocopying,photocopying. recording,recording. or other• wise,wise. without the prior written permission of the publishers.publishers, Martinus Nijhoff Publishing,Publishing. 190 Old Derby])erby Street.Street, Hingham,Hingham. MA 02043, USA. PRINTEDPRI:t\rTED IN THE UNITED STATES.

DISTRIBUTORS

for the United States and Canada: Kluwer Academic Publishers, 190 Old Derby Street.Street, Hingham,Hingham. MA.MA, 02043, USA for the UK and Ireland: Kluwer Academic Publishers.Publishers, MTP Press Limited,Limited. Falcon House,House. Queen Square, Lancaster LAlLA1 1lRN,RN, UK for anal]l other countries: Kluwer Academic Publishers Group.Group, Distribution Centre, P.O. Box 322, 3300 AH Dordrecht.Dordrecht, The Netherlands

LibraryLibr~lry of Congress Cataloging-in-Publication Data Main entry under title: Clinical neuropsychology of intervention. Includes bibliographies and index. 1. damage. 2. Brain damage-Patients• Rehabilitation. 3. Neuropsychological tests. I. U2:Zell.U2;zell, Barbara P. II. Gross.Gross, Yigal. [DNLM: 1. Brain Injuries-rehabilitation. 2. Neuropsychology• methods. WL 354 C6413jC6413] RC387.5.C56 1985 616.8 85-15498 ISBN-13:ISBN 0-89838-756-6978-1-4612-9412-2 e-ISBN-13: 978-1-4613-2291-7 DOl: 10.007/978-1-4613-2291-7 CONTENTS

Contributing Authors Vll Foreword by Edith Kaplan xii Preface xv

I. ORIGINS OF INTERVENTION 1 1. Pathophysiology and Behavioral Recovery 3 Barbara P. Uzzell

D. ASSESSMENT FOR INTERVENTION 19 2. The Ecological Validity ofNeuropsychological Assessment and Remediation 21 Tessa Hart and Mary Ellen Hayden 3. Qualitative Neuropsychological Assessment: Kurt Goldstein Revisited 51 Herbert Kohn 4. Cognitive Assessment in the Neuropsychological Rehabilitation of Head-Injured Adults 59 Keith D. Cicerone and David E. Tupper 5. Relationships Between Test Scores and Everyday Life Functioning 85 Mary Bryant Acker 6. Competency Assessment in Clinical Populations: An Introduction to the Cognitive Competency Test 119 Paul L. Wang and Karen E. Ennis

v vi

7. Cognitive, Personality and Psychosocial Factors in Neuropsychological Adjustment ofBrain-Injured Patients 135 George P. Prigatano, Mary Pepping, and Pamela Klonoff

III. INTERVENTION TECHNIQUES AND STRATEGIES 167 8. Applying Luria's Theory to the Rehabilitation Process of Brain Damage 169 Anne-Lise Christensen 9. Intervention Models in Neuropsychology 179 Yigal Gross and Larry E. Schutz to. Skills, Routines, and Activity Patterns ofDaily Living: A Functional Nested Approach 205 Nathaniel H. Mayer, Daniel]. Keating, and Dorrie Rapp 11. Management of Persisting Communication Deficits in Patients with 223 Sandra B. Milton and Robert T. Wertz 12. Remediation: Restoration, Alleviation and the Acquisition of Domain-Specific Knowledge 257 Daniel L. Schacter and Elizabeth L. Glisky 13. from Failures in Perceptual Cognitive Retraining in Stroke Leonard Diller and Joseph Weinberg 283 Index 294 CONTRIBUTING AUTHORS

Mary Bryant Acker, Ph.D. Hospital Psychology Services Program Manager Santa Clara Valley Medical Center San Jose, California, 95128, U.S.A. Anne-Lise Christensen. C. Psychol. Director ofRehabilitation Center for Rehabilitation ofBrain Damage University ofCopenhagen, Amager Nialsgade 88 2300 Copenhagen S., Denmark Keith D. Cicerone, Ph.D. Clinical Director ofthe Cognitive Rehabilitation Department LiFEstyle Institute 2050 Oak Tree Road Edison, NewJersey, 08820, U.S.A. Leonard Diller, Ph.D. Director ofPsychology in Behavioral Sciences Rusk Institute ofRehabilitation Medicine Professor ofClinical Rehabilitation Medicine New York University Medical Center

vii viii

400 East 34th Street New York, New York, 10016, U.S.A. Karen E. Ennis, Ph.D. Psychology Staff Mount Sinai Hospital Department ofPsychology 600 University Avenue Toronto, Ontario, Canada M5G lX5 Elizabeth L. Glisky, Ph. D. Research Fellow Unit for Memory Disorders Department ofPsychology University ofToronto Toronto, Ontario, Canada M5S 2)5 Yigal Gross, Ph.D. Senior Lecturer Department ofPsychology Bar-Han University Ramat-Gan; Director ofDevelopment and Training The Neuropsychological Unit for Treatment and Rehabilitation Givatayim, Israel Tessa Hart, Ph.D. Director ofResearch Department ofNeuropsychology Medical Center Del Oro Hospital 8081 Greenbriar Dr. Houston, Texas, 77054, U.S.A. Mary Ellen Hayden, Ph.D. Director Department ofNeuropsychology Medical Center Del Oro Hospital 8081 Greenbriar Dr. Houston, Texas, 77054, U.S.A. Edith Kaplan, Ph. D. Director of Clinical Neuropsychological Services Boston Veterans Administration Medical Center; Associate Professor ofNeurology (Neuropsychology) Boston University Medical Center Boston, Massachusetts 02118 ix

Daniel J. Keating, Ph. D. Unit Director Intermediate Living Skills Program Drucker Brain Injury Center Moss Rehabilitation Hospital 12th Street and Tabor Road Philadelphia, Pennsylvania, 19141, U.S.A. Pamela Klonoff, Ph.D. Postdoctoral Fellow Section ofNeuropsychology Department ofNeurosurgery Presbyterian Hospital University of Oklahoma Health Science Center Oklahoma, Oklahoma, 73104, U.S.A. Herbert Kohn, Ph.D. Associate Professor ofPsychiatry Department ofPsychiatry UMDNJ-Rutgers Medical School Piscataway, NewJersey, 08854, U.S.A. Nathaniel H. Mayer, M.D. Professor, Rehabilitation Medicine Temple University Health Sciences Center Director, Drucker Brain Injury Center Moss Rehabilitation Hospital 12th Street and Tabor Road Philadelphia, Pennsylvania, 19141, U.S.A. Sandra B. Milton, M.A., c.c.c.-Sp. Director Head Injury Rehabilitation Consulting Services 6317 Wilshire Boulevard, Suite 402 Los Angeles, California, 90048, U.S.A. Mary Pepping, Ph.D. Director, Section ofNeuropsychology Department ofNeurosurgery Presbyterian Hospital University of Oklahoma Health Science Center Oklahoma, Oklahoma, 73104, U.S.A. George P. Prigatano, Ph.D. Chairman ofDepartment of Neuropsychology Clinical Director ofNeurological Rehabilitation x

Barrow Neurological Institute 350 West Thomas Road Phoenix, Arizona, 85013, U.S.A. Dorrie: Rapp, Ph.D. Clinical Assistant Professor Department ofMental Health Sciences Hahnemann University Clinical Neuropsychologist 7906 Chandler Road Laverock, Pennsylvania, 19118, U.S. A. Daniel L. Schacter, Ph.D. Assistant Professor Unit for Memory Disorders Department ofPsychology University ofToronto Toronto, Ontario, Canada M5S 2J5 Larry E. Schutz, Ph. D. Clinical Director Head Injury Center at Manatee Springs 5627 9th Street East Bradenton, Florida, 33507, U.S.A. David E. Tupper, Ph.D. Staff Cognitive Rehabilitation Department LIFEstyle Institute 2050 Oak Tree Road Edison, NewJersey, 08820, U.S.A. Barbara P. Uzzell, Ph.D. Clinical Neuropsychologist Research Assistant Professor Division ofNeurosurgery Hospital ofthe University ofPennsylvania 3400 Spruce Street Philadelphia, Pennsylvania, 19104, U.S.A. Paul L. Wang, Ph. D. Director ofNeuropsychology Mount Sinai Hospital Department ofPsychology 600 University Avenue Toronto, Ontario, Canada M5G 1X5 xi

Joseph Weinberg, M.A. Senior Psychologist Rusk Institute ofRehabilitation Medicine New York University Medical Center 400 East 34th Street New York, New York, 10016, U.S.A. Robert T. Wertz, Ph.D. Chief, Audiology and Speech Pathology VA Medical Center 150 Muir Road Martinez, California, 94553, U.S.A. FORI~WORD

It is estimated that 400,000 to 500,000 individuals who have sustained a trau• matic head injury are admitted to hospitals every year. Of these, 40,000 to 50,000 have moderate to severe head injury causing significant enduring dis• abilities. Another 70,000 to 90,000 have minor head injuries with persistent sequelae such as memory and/or behavioral problems that preclude imme• diate return to the workplace. Contributing further to the problem is the fact that the largest number of head injury victims are below the age of 30 and have a considerable life expectancy. It is, therefore, not surprising that there has been a recent proliferation of cognitive rehabilitation centers. In 1980, when the National Head Injury Foundation was established, there were only 22 idlentified cognitive rehabilitation centers. In 1985, the resource guide of the National Head Injury Foundation lists 350 cognitive rehabilitation centers dedicated to address the overwhelming needs of the head injured and their familites. Concomitant with this rapidly growing increase in the number of facilities, there have been remarkable developments in clinical imaging tech• nology that have expanded our knowledge of the affected neural substrate and the behavioral consequences. In conjunction with these advances, pro• fessionals in the rapidly evolving field of clinical neuropsychology have be• come cognizant of the need to expand their role as clinicians to meet the increasing demands for treatment of the brain injured. As a result, there has been a move in the direction of assessment of processes or strategies that a patient employs (whether they be adaptive or maladaptive), rather than the xii. xiii

more traditional psychometric focus on the end product or final achievement (scores or tests). This approach, akin to that ofA.R. Luria, is more congenial to the needs for prescriptive intervention and has resulted in the revival of in-depth testing of clinical limits to identify those variables that will induce a better performance, thereby beginning intervention during the initial assess• ment. Subsequent assessments serve two major functions: one, monitoring the efficacy of an intervention and, two, modifying therapeutic techniques to maximize their impact. Though in principle this relationship between assess• ment and intervention is simple, in practice the issues regarding the nature of the contents of the instruments for assessment and specific techniques for intervention are complex and must be addressed. Drs. Barbara Uzzell and Yigal Gross have ably responded to this need. Their sensitivity to the myriad problems involved in assessment and treat• ment is immediately evident in both the organization of this book and their selection of contributors. Throughout the book, issues that confront rehabili• tation providers faced with accountability requirements are comprehensively examined. The role of such factors as pathophysiology, spontaneous re• covery, long-term pre-existing cognitive and personality problems (fre• quently predisposing to injury), the head-injured patient's personal reaction to his/her deficits, the multifactorial nature of tests, the relevance of test con• tents for the patient, ecological validity of tests and treatment procedures, learning potential, deficits in language and communication, memory, sen• sory, and psychosocial are all examined and discussed relative to assessment, intervention techniques, and outcome predictions. It is heartening to see single case studies that at the turn of the century permitted the identification of the varieties of , apraxia, agnosia, and such disconnection syndromes as alexia without agraphia are again recog• nized for the contribution they can make to the better understanding of brain-behavior relationships and individualized rehabilitation. The necessity to use and further develop theoretical models to guide the use of specific intervention techniques, as well as contemporary theories that derive from research in cognition and relaxed disciplines, is demonstrated in the section of the book devoted to neuropsychological intervention. Each chapter in this eminently readable book addresses an important prob• lem area, and illuminates the expanding role of the neuropsychologist and speech and language pathologist in the rehabilitation setting. Creative, novel techniques are articulated and richly illustrated with case histories. The authors are modest in their claims, readily acknowledging limitations and the need for further research. The questions that are raised reflect the state of the art, but more importantly, they suggest the direction of future research and the development of more sensitive and ecologically valid assessment instru• ments as well as intervention techniques that will have an enduring effect, and permit transfer and greater generalizability. Without question, this book represents a major contribution to the field. xiv

Drs. Uzzell and Gross are to be commended for conceiving and realizing this comprehensive work, which has the potential for ultimately improving the quality of life of the head-injured patients and that of their families.

Edith Kaplan, Ph.D. June 1985 PREFACE

Neuropsychology has been concerned with brain-behavior relationships. Clinical neuropsychology has been concerned with application of relation• ships to clinical problems. As interest in these topics continues, a spin-off from clinical neuropsychology has been the realization of the potential of de• lineations of behavioral consequences of cerebral lesions for developing and evaluating restoration and compensation objectives. Methods for these proce• dures are scattered in books, journal articles, or else unwritten, and only in the minds of clinicians. Questions need to be addressed regarding the kinds of assessment selections required; the types of rehabilitation planning; the in• fluences of the environment, communication, and personality; and the means of effectively evaluating rehabilitation procedures. A useful book is needed by clinicians working in this area. The purpose of this book is to consolidate, in one volume, current work• able approaches of a subdiscipline within neuropsychology and related areas which we are calling Intervention. Problems, dilemmas, solutions, and choices are presented to the reader beginning to work in this fascinating area, and to those of us already enthralled by previous developments and outcomes. Workers with expertise in assessment for intervention and interventiop strategies are chapter contributors who unravel issues, provide available em• pirically based theory, illustrative data, and case reports. The volume begins with a chapter that emphasizes an awareness of the potential usefulness of pathophysiology, and the recognition of spontaneous

xv xvi

recovery in relationship to intervention. Part II of the book is devoted to identifying and developing assessment techniques relevant for intervention. Present strengths and limitations of standardized neuropsychological tests for understanding cognitive, personality, and psychosocial disorders are re• viewed. Factors including the appropriateness of extrapolating test results from group data to the individual case, from generalizing from one disability group to that of another, and the focus on test-relevant skills for carryover to environment-relevant skills are addressed. Solutions for supplementing tradi• tional assessment and avoiding pitfalls are presented. These include: qualita• tive approaches, delineation of test classification in terms of functional life activities, and the development oftests representative ofadult daily activities. Th(: goal of part III is to provide intervention approaches. The importance of relevant theory in guiding rehabilitation oftreatment targets and process is addressed. Methods of treatment and appraisal, viable memory treatments, communication considerations, and the utilization of information from treat• ment failures are offered within an empirically based framework. While principally aimed at providing information regarding clinical neuro• psychology of intervention, hopefully this book will have a number of general effects. One is to lessen the complexities and minimize the failures of assessment and intervention by identifying relevant and irrelevant factors, and by consolidating empirically based methods within one book. Another is to clarify interpretative and theoretical issues in order to stimulate new conceptual advances. Most of all, it is hoped that the book will stimulate re• habilitation clinicians to develop and utilize effective intervention. We want to thank all persons who contributed time and effort to make this book possible. We especially want to thank the following: the contributing authors for their willingness to share their approaches and experiences with the reader; and the secretary, Toby Laiken, who worked tirelessly to insure the book's completion.