The Behavioural Management of Neglect
Rusk Institutre of Rehabilitation Medicine, MYU MC, USA
Jewish Home & Hospital for the Aged, Bronx, NY, USA
Introduction
Visual neglect denotes diminished awareness of space opposite to a damaged hemisphere. It has sometimes been referred to as hemineglect, spatial neglect, imperception, hemi-inattention, unilateral spatial agnosia, or visual spatial agnosia. Recent work has attempted to quantify observations with more precise measures to develop taxonomies of visual neglect (Gianutsos & Matheson, 1987), and to search for the causes and correlates of neglect. Thus visual neglect has been attributed to derivatives of impairment of defective visual processes (Battersby, Bender, Pollack, & Kahn, 1956; Gianutsos & Matheson, 1987) and attentional disturbances (Heilman, 1985). Historically, there have been attempts to relate visual neglect to motivational aspects of denial (Weinstein & Kahn, 1955). Application of cognitive science to clinical problems (McGlynn & Schachter, 1989) adds a new dimension to help understand visual neglect. In earlier work we found visual neglect was not a simple absence or deficiency in a skill, but consisted of several subsets of deficits involving motor impersistence, visual field cut, extinction, impulse control (Diller & Weinberg, 1977) and sluggish eye movements (Johnston, 1984). In addition, neglect is manifested in free-field search rather than being confined to delimited test conditions (Halligan, Marshall, & Wade, 1990).
From a rehabilitation perspective, neglect is not only a discrete clinical entity or part of a neuropsychological syndrome to be diagnosed and studied, it is a behaviour pattern with important prognostic consequences (Lorenze & Cancro, 1962) and management concerns in rehabilitation. Given the problem which might be manifested in clinical or testing situations, what does one do to assist an individual who is disabled by this condition to return to normal living? The path we have followed and the leads we are pursuing will be the subject of this chapter.
This work has been concerned not only with techniques for altering neglect, but also with attempting to alter functional behaviours associated with neglect, developing methodology and principles to guide instruction in rehabilitation, and examining and addressing some of the clinical issues associated with neglect which impact rehabilitation. This chapter can be split into four sections: (1) studies conducted between 1966 and 1982; (2) studies conducted between 1983 and 1987; (3) current studies; and (4) future directions. Some of the earlier work has been summarised (Diller & Weinberg, 1977; Weinberg et al., 1977, 1979; Weinberg, Piasetsky, Diller, & Gordon, 1982). Most of the later work has been unpublished and will be presented here in more detail.
Our original approach to the management of visual neglect in a medical rehabilitation setting was to (1) define a central construct which expresses neglect; (2) develop an indicator of neglect which could be sensitive to change; (3) study the clinical correlates and (4) experimental conditions which influence neglect; (5) develop strategies for effecting change on the indicator; (6) identify functional markers as equivalents of the central indicator to test for the practical efficacy of the strategies; (7) develop further strategies for treating behaviours which had not been amenable to change. In the course of these studies, we found that both principles and procedures emerged to help promote an instructional frame for interventions. Since neglect is a complex phenomenon, each set of findings led to further questions touching eventually on the non-visual perceptual issues of arousal, depression and unawareness. Clinical management led to a wider range of considerations than originally anticipated. We therefore divide our presentation into phases to trace the path we followed to indicate some of this complexity.
Defining and Altering Visual Neglect: A Review of Early Studies (1966–82)
A disturbance in visual scan is a central problem in neglect. In studying attention in individuals with right brain damage (RBD), we distinguished between disturbances via sensory modality (visual vs auditory, scan vs span). Scan refers to the aspect of attention involved in searching the environment (cancellation tasks). Span refers to the capacity for retaining information from the environment (digit span tasks). In presenting both types of tasks via auditory and visual modalities, in RBD the primary disturbance was visual scan. Visual cancellation became a useful indicator of the severity and nature of a visual scanning problem. The primary problem in RBD was errors of omission on a cancellation test, while the primary problem in left brain damage was slowness rather than errors (Diller & Weinberg, 1968).
To trace correlates of visual scanning disturbance, tests as well as observations in rehabilitation and natural settings were used. In addition to correlations with expected tests such as bisecting a line or Raven’s Progressive Matrices, unexpected correlates emerged, including displacement to the right in the location of the backbone when touched along the shoulder (a sensory spatial task) and difficulty in reciting digits backwards (an auditory task). A wide network of problems in activities of daily living were found, including: accidents in learning to walk or transferring to and from a wheelchair (Diller & Weinberg, 1970); omission of food items on a hospital menu or missing food on the side of a tray; disturbance in grooming and dressing activities; and difficulties in reading. These difficulties were generally dismissed by patients (Diller & Weinberg, 1968) or attributed to external superficial factors (“Yes, I can read, but I left my glasses in my room”). Problems which are often unacknowledged lead to fear of social engagements due to misreaching for a cup of coffee, for example, or not being able to read a restaurant menu. In turn, avoidance of activity in public places or reduced recreational pursuits, such as going to theatres or concerts, become more prominent after in-patient treatment is finished. Extensive probing indicated that patients were often afraid that they were losing their sanity.
On cancellation tasks, varying the instructions can increase or decrease the manifestations of neglect. For example, the patient performs often differently if instructions are to start at the right or left, or to scan freely. Responses to instructions provided useful clues in developing clinically meaningful interventions. One could build training by starting with simple conditions and then increase the demand level. Thus factors such as instructions as to where to begin or altering size and density of stimuli could increase or decrease neglect (Diller et al., 1974).
Combining results from previous studies, three clinical training programmes in visual information processing (VIP) were developed. Each was built on the results of prior training programmes. It was possible to (a) improve scanning and the mechanics of reading and written arithmetic; (b) appreciate space on and off the body; and (c) enhance the search in figure ground problems (Weinberg et al., 1977; 1979; 1982). The procedures developed for each programme were derived from the more generic principles used with different kinds of materials and adapted to different rehabilitation environments (see Table 14.1).
Table 14.1
Principles of Scanning Training
|
We used a “scanning machine”, which is a board with a target that can be moved around the periphery and requires the patient to point to the target as it moves. The board was studded with lights, also serving as targets, to explore such phenomena as simultaneous stimulation and extinction (Weinberg et al., 1977). One virtue of the scanning machine was that it permitted engagement of patients who denied problems and rejected paper and pencil activities which are perceived as childish or a source of embarrassment when failed. Cancellation tasks were a primary tool to apply the principles because of their flexibility.
Combining previous interventions into a package and testing its effects, an experimental group was able to hasten improvement in skills and read more during leisure time on follow-up than a control group (Gordon et al., 1985). However, for the most part, the control group had caught up with the experimental group at 4 months follow-up. Despite improvements in both groups, cancellation measures were still far below normal and patients appeared to be depressed, socially isolated and passive.
Exploring Non-Visual Correlates of Neglect: Studies 1983–1987
Two questions were posed. The first was what the relationship is between visual neglect, depression, arousal and comprehension of affect. As indicated, depression and hypoarousal appeared to be prominent in the follow-up of patients (Gordon et al., 1985). Difficulties in affect comprehension might be an important marker in studying depression. In a study involving individuals with RBD who showed visual field defects (n = 71), there was a high incidence of difficulty in measures of VIP (91%), arousal (87%), depression (76%) and affect comprehension (80%). These problems were also common in people with RBD who had normal visual fields n = 79) : VIP (61%), arousal (49%), depression (58%) and affect comprehension (60%) (Diller, Goodgold, & Kay, 1988). These disturbances, if untreated, remain at 1 year follow-up (Egelko et al., 1989). Disturbance in VIP without disturbance in affect or arousal is a rare event. Only 2% of patients with visual field defects and 4% of patients without visual field deficits had VIP problems alone.
The second question asked what the effect is of treating hypoarousal along with neglect. Arousal training was added to VIP training in a study which posed the question which training strategy was more effective, a depth programme which emphasised overlearning, or a breadth programme which emphasised generalisation? In the depth (overlearning) condition, a highly specific group of skills targeted to VIP was taught. Several exercises were repeated on a consistent, daily basis. The training materials were identical to those used in previous studies. They were accompanied by the orientation remediation module (ORM), a series of attention exercises developed for individuals with traumatic brain injury (Ben-Yishay, Piasetsky, & Rattok 1987), which were adapted for stroke patients to increase arousal. This highly structured context provided the opportunity to continue skill acquisition to the point of overlearning. Patients were challenged to maintain attention during repetitive exercises.
In the breadth (generalisation) condition, emphasis was placed on optimising consistent performance across a variety of tasks, rather than focusing on a specific task. Thus a given generic skill (lateral visual scanning) was practised in a variety of contexts. It was hypothesised that a broad range of exercises in treatment sessions would yield better carry-over to daily functioning. Less emphasis was placed on repeating VIP and ORM exercises, and more meaningful and personally relevant tasks were developed in consultation between the remediator and the patient (e.g. reviewing blueprints with an architect, menus with a chef). This model was designed to show patients how a generic skill deficit can interfere with functioning and heighten engagement in treatment by using personally relevant stimuli. Most importantly, with less uniform stimuli and task and environmental diversity, a wider degree of transfer and maintenance of skills over time was sought. The basic principles of treatment in the different models are the same (see Table 14.1), but the utilisation of tasks, the level of repetition, diversity, and the spatial environment in which the treatment occurs vary considerably.
Prior to the implementation of the depth and the breadth models, we had not attempted to treat the arousal/attention deficits associated with RBD and neglect. Based on the frequent co-existence of these deficits, and the encouraging findings in treating arousal/attention deficits in young traumatically brain-damaged adults (Ben-Yishay et al., 1987) and pilot studies in our programme, computerised exercises in simple reaction time, perceptual motor training and estimation of time intervals were incorporated into both models of treatment. Along with VIP training, the depth model emphasised daily repetition of these tasks, while the breadth model utilised them in conjunction with other tasks designed to increase alertness and participation in treatment. These tasks included engaging the patient in conversation on topics of personal interest, having the patient sort stimuli as quickly as possible, or engaging in semantic tasks, such as unscrambling sentences. The goal in both cases was to increase the patients’ activation, directed attention, environmental responsivity and anticipatory alertness.
All consecutively admitted RBD stroke patients were screened for this study. To qualify for the programme, the patients had to meet the following criteria: at least 3 weeks post-onset unilateral stroke; neuroradiological evidence confirming the diagnosis of a unilateral RBD; right-handed for writing; primarily English speaking; corrected reading visual acuity of at least 20/85; between the ages of 45 and 85 years; no history of central nervous system (CNS) or psychiatric disturbance; and a passing score of 20 or above on a screening examination for dementia, the Mini-Mental State Exam (Folstein, Folstein, & McHugh, 1985). Only patients who met the criteria for deficits in the VIP or the arousal domain were accessed into this phase of the treatment studies. All patients who met the criteria for the study were assigned to either depth (n = 21), breadth (n = 16) or control group (n = 41). The latter received conventional occupational therapy, which typically is concerned with improving visual spatial functioning and encouraging patients with neglect to attend to the left. Within 2 weeks of admission, all patients were administered the full psychometric battery, listed in Table 14.2. The patients in the depth and breadth conditions received a minimum of 12 h of treatment and a maximum of 40 h of treatment. (Prior studies adopted a minimum of 20 h of treatment, but decreased rehabilitation in-patient stays to an average of 34 days at the time of this study, necessitated a change in this criterion.) All patients were retested prior to discharge (T2) and 5 months post-discharge (T3).
Table 14.2
Psychometric Battery for Interventions
Visual information processing (VIP) |
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Double cancellation (cancel two targets) |
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Line bisection: left, right |
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Lateral asymmetric visual spatial attention (Piasetsky, 1981) |
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Raven’s Coloured Progressive Matrices (RCPM) |
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Wide range achievement: reading |
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Simple written arithmetic |
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Facial recognition (Benton, Van Allen, Hammisher, & Levin, 1975) |
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Midline |
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Block design (WAIS-R) |
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Arousal-attention |
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Computerised reaction time (Ben-Yishay et al., 1987) |
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Computerised time estimates (Ben Yishay et al., 1987) |
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Portable reaction time |
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Motor inhibition (Downey, 1934) |
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Mini-Luria motor (6 motor items from the Luria Nebraska Motor Scale: Golden, 1981) |
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Rate of performance on double cancellation |
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Depression |
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Beck Depression Inventory (Beck et al., 1961) |
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Hamilton Rating Scale of Depression (Hamilton, 1967) |
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Multiple Affect Adjective Check List (MAACL) (Zuckerman & Lubin, 1965) |
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Cognitive flexibility |
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Mini mental state (Folstein et al., 1975) |
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Conceptual level analogy test (RCPM) (Willner & Strune, 1970) |
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Affect comprehension |
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Auditory affect comprehension (Unpublished) |
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Visual affect comprehension (Unpublished) |
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Miscellaneous verbal markers |
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Word fluency |
(FAS: Spreen & Benton, 1969) |
Digit span |
(WAIS-R) |
Comprehension |
(WAIS-R) |
Similarities |
(WAIS-R) |
A series of covariance analyses was conducted with group (depth/ breadth/control) serving as the independent variable, T2 performance as the dependent measure and T1 performance as the covariate. These analyses revealed that the group effects which emerged from this study were primarily on the arousal measures. The depth and the breadth patients were significantly different from the controls on variable ORM reaction time, and the depth patients were significantly different from the controls on the fixed ORM reaction time. The depth and breadth patients were significantly different from the controls on clinical ratings of alertness, summed over 3 days of testing. (This effect should be interpreted cautiously as the testers were not blind to treatment condition.) There were also trends for the breadth patients to be less depressed and to perform better on the WAIS-R Digit span than the depth patients. The fact that the depth and breadth patients performed significantly better than controls on the post-treatment arousal measures indicates that both treatment models impacted on the arousal deficits of these patients. Within-group t-tests comparing T1−T2 performance separately for the three groups were also conducted. The control patients improved significantly on 7 core visual measures, while the depth and breadth patients improved significantly on 8 and 10 visual measures, respectively. In contrast, the control patients did not improve on any core arousal measures from T1 to T2, whereas the depth and breadth patients improved on 6 and 5 arousal measures, respectively.
The covariance analyses of the 5-month post-discharge data indicated that the gains on the arousal measures were maintained over time. The breadth patients also performed better on a left-sided line bisection task, i.e. bisecting a line on the left side of a page, as opposed to the centre or right side of the page. This task is very sensitive to right hemisphere damage as measured on CT scan (Egelko et al., 1988) and is what we have termed a “far transfer” task, i.e. one that was not used directly in treatment. The T1 deviation scores (measured in millimetres from the centre of the line) were as follows: breadth (16.9 mm) depth (15.9 mm), control (9.9 mm). At follow up, the breadth group improved to 9.9 mm at T2 and continued to improve to a score of 6.8 mm at T3. The depth and control groups improved slightly at T2 (13.3 and 8.6 mm, respectively) and those scores were maintained at T3. This provided some encouraging evidence that the breadth model had a more sustained effect. There were also trends for the breadth patients to perform better than the controls on WRAT reading, a test with high face validity for real life functioning.
The T1– T3 within-group t-tests suggested that the pattern of results which emerged at T2 was maintained over time. Specifically, the three groups looked similar with respect to their performance on VIP measures. The control patients did not improve significantly on the arousal measures, whereas the depth and breadth patients did improve in this domain. Moreover, the T1– T3 results suggest that the impact of the intervention programme in the arousal domain was better maintained over time in the breadth group. At discharge, the two experimental groups were comparable in the number of measures they improved on, relative to admission. Upon follow-up, however, the depth patients changed significantly on two measures, whereas the breadth patients changed on four. The fact that treatment-related gains in the arousal domain were better maintained in the breadth patients, provides evidence of the more generalised effect of the breadth model, relative to the depth model. An analysis of the activity patterns of patients upon follow-up at home revealed that the breadth patients spent time outside of the home more frequently than the depth or the control patients. Social isolation and reduction of leisure activities have been documented as persistent and prevalent problems among long-term stroke survivors (Feibel & Springer, 1982; Labi, Phillips, & Gresham, 1980). These problems are correlated with depression and are independent of severity of physical dysfunction. The finding of higher and more frequent levels of activity outside of the home in breadth patients fits with the gains noted in the arousal measures and may represent a generalised treatment effect with regard to alertness or energy level. The findings take on additional meaning in view of our previous study (Gordon et al., 1985), which involved only VIP training and did not yield an effect on activity patterns at 4 months follow-up.
A question which arises in the face of these results is why the treatment effects in this phase of our work was less pronounced on the VIP measures than in previous studies. The experimental patients did improve on VIP measures, but the control patients improved as well, and there was a great deal of variability on these measures both in terms of initial level of performance and degree of change. A variety of factors which may have contributed to this pattern of results speak to some pertinent issues about the treatment programme. First, the amount of time directed to the treatment of visual deficits in this phase of our studies was greatly reduced, relative to earlier phases, due to the combined treatment package for visual and arousal deficits, as well as to reduced in-patient stays. Patients in prior studies received between 30 and 35 h of VIP treatment. In this study, patients were selected on the basis of moderate-to-severe visual deficits, and sometimes received as few as 12 h of treatment, which targeted both VIP and arousal deficits.
To examine the impact of reduced stays on treatment-related gains, t-tests were used to compare the admission and discharge scores of those patients who received more than 20 treatment sessions to those who received less than 20 treatment sessions. The patients who received more than 20 treatment sessions, primarily as a result of longer hospital stays, were significantly more impaired at admission than the group which received less treatment. However, there were no significant differences between these two groups at discharge, suggesting that the more impaired group, which received more treatment, was brought up to the level of performance of the other group. These findings must be interpreted somewhat cautiously, as the more impaired group was younger, and the natural recovery of younger patients might account for these findings. Although the interpretation is ambiguous, it is rather compelling that these groups were significantly different on 12 core measures at admission, and that there were no significant differences at discharge.
Another set of factors may have led to a more pronounced effect on the arousal vs VIP results of this study. First, moderate and severe neglect patients were selected for treatment, based on their performance on a double letter cancellation task, eliminating the contamination of ceiling effects, but reducing the variability of performance at the base of the measure. In addition, the reaction time measures were derived from repeated observations for each patient, and reciprocal transformations were used to control for high outlying values, thereby providing a more stable measure of performance than is possible with any given VIP measure. Lastly, the programme of treatment research in our department had focused for the past 15 years on the visual deficits associated with neglect, and the restoration of orderly visual scanning. These remediation techniques have been widely disseminated and incorporated by other services within the institution, particularly occupational therapy. While this institutional effect is extremely beneficial clinically, the “control group” in our studies is not untreated but another group receiving similar but less focused treatment.
The group design model means that patients receive either a depth or a breadth treatment. From a clinical perspective, however, the depth model may be more effective for more severe patients and patients in the earlier stages of recovery, whereas the breadth model may be more effective for the milder patients and patients in the later stages of recovery. The depth model establishes the foundation of well-practised compensatory mechanisms, the patient’s responsiveness to anchoring and cueing, through the use of uniform, repetitive and highly structured tasks. With a less severe patient, or a patient in the later stages of recovery, it may be more important to diversify the treatment tasks, the spatial environments in which treatment occurs, and the “transfer of responsibility” for cueing from the clinician to the patient. Ultimately, for treatment effects to be maintained over time, and different environmental and stimulus conditions, the neglect patient must self-cue.
Our early work in the treatment of neglect emphasised the development of a platform of skills. This stage of our work has emphasised the development of models or styles of treatment. Future work might focus on the development of a platform of treatment styles within a given module for a given patient. What is the optimum combination of the depth and the breadth approach, and how much of the treatment should be targeted to arousal deficits for any given patient, at any given stage of recovery? What works for whom and when?
In conclusion, current theories of neglect have focused on disturbances in the rapid, automatic shifting of visual attention—emphasising a disturbance in the disengagement of attention (Gianotti, D’Erme, Montebone, & Silveri, 1986), a disturbance in the shifting of attention (Posner, Walker, Friedrich, & Rafal, 1984), underarousal and hypokinesia (Heilman, 1985) and orientation to the impaired side of brain damage (Kinsbourne, 1977). The principles of anchoring and cueing, the hierarchy of treatment procedures, and the models of treatment are consonant with all of these theories. The fact that patients receiving arousal training were more active on follow-up in distinction to our prior study suggests other dimensions than straight VIP training yield an important impact on outcome. In implementing programmes, we observed that engagement and responsiveness to treatment were related to the awareness of the problem. While methods were designed to bypass unawareness, it was an important consideration. The observation was supported by a study described below.
Unawareness: Current Studies (1988-Present)
A cardinal feature of neglect—lack of awareness—has been noted by many (e.g. McGlynn & Schachter, 1989). From a remedial perspective, a number of leads might be useful. For example, when patients in the depth/breadth study were asked to state their problems and probed for changes in thinking, concentration and perception, three judges were able to rate the responses reliably (intraclass r = 0.88). The patients who were more aware of problems showed the most improvement on the VIP measures in all three conditions (breadth, depth and control). Awareness correlated with improvement scores while demographic, neurological and neuropsychological measures were not predictors of change. Awareness as a predictor of change and responsivity to treatment seemed worthy of further exploration.
The findings suggest three paths of study which are currently under investigation: the nature of verbal awareness of problems; the examination of non-verbal or “behavioural” awareness; and the analysis of response styles when being made aware of a problem.
Assessing Verbal Awareness
Students of the problem have distinguished between unawareness, as a function of brain damage, and denial, as a function of a motivated drive to avoid unpleasant experience. In rehabilitation, this distinction may be too simple. Awareness of deficit in rehabilitation of stroke patients encompasses a wide range of events including acknowledgement of stroke, paralysis, perceptual and cognitive difficulties, and anticipation of future consequences or implications of physical or cognitive deficits. Awareness can be examined along several dimensions. One dimension is the degree to which deficits are visible to the patient. Thus a paralysis is visible and offers a continuous reminder to the individual experiencing it. A perceptual deficit is not visible to the patient; its presence has to be inferred. Anderson and Tranel (1989) found that stroke patients endorsed the presence of visible impairments more frequently than they endorsed the presence of non-visible impairments. Barco et al. (1991) suggested another dimension. They noted distinctions between intellectual, emergent and anticipatory awareness in traumatically brain-damaged people which may be applicable to stroke patients. Anticipatory unawareness may be manifested in the observation, that it is common for stroke patients to postpone planning for the future as a consequence of impairments due to stroke (Powell, Diller, & Grynbaum, 1976).
To provide a systematic method for assessing the acknowledgement of the full range of problems associated with neglect and rehabilitation, we are developing an instrument called the Rusk Evaluation of Awareness of Deficits in Stroke (READS). This instrument is in an interview format, and involves a layered approach to inquiry ranging from spontaneous statements concerning presence of problems to cued questions. In a preliminary study of patients with RBD, those with mild neglect (n = 18) rated themselves as equally impaired to those with severe neglect (n = 21). Awareness in mild patients is related to actual perceptual impairment. For severe patients, awareness is positively related to cognitive intactness (Simon et al., 1991).
Non-Verbal Awareness
In a remedial situation, one may respond to cueing without verbal acknowledgement. This situation is similar to occurrences which have been cited in the procedural learning literature and may be related to implicit awareness (McGlynn & Schachter, 1989). We designed a four-tiered cancellation task to sample response to remediation. It consists of the following: (1) administration of a standard cancellation test; (2) administration of cancellation with remedial instructions and cueing, e.g. draw anchor on the left, say anchoring but no instructions. This approach samples the ability to profit from instruction and cues under structured and spontaneous conditions. It is similar in approach to Luria’s (1961) zone of potential. This measure taps an individual’s capacity for enhancing performance, but does not require explicit verbalisation.
Unawareness as Response Style
During remediation, a wide range of responses to confrontation with an unacknowledged problem can be observed. This may pose a clinical management problem in establishing and maintaining the rapport which is vital in a learning situation. Patients are often unaware of the VIP deficit, confused by their unawareness, and struggle to respond to cueing and reminders. Sometimes types of awareness may be disassociated. Thus, a patient can describe the deficit and yet act as if the deficit did not exist. For example, after spontaneously reporting a conversation with her physician about remediation and describing the importance of anchoring on the left side of space, a patient described only the right side of the room. When confronted with omission, responses vary from hostile resistance to making excuses for task failure (e.g. “I forgot my glasses”, “I’m not interested”) to initial resistance and reluctant acknowledgement to self-correction. In the course of perceptual remediation (Diller & Weinberg, 1993), we noted that it was possible to develop a typology of response styles in dealing with unawareness from active resistance to acceptance. The response styles were related to severity of impairments on cancellation tasks as well as other measures. This suggests that for the severe neglect patient, active resistance occurs because a reminder is seen as intrusive and discontinuous with current experience.
Some Future Directions in Remediation of Neglect
We have approached perceptual remediation as a problem in teaching and learning and found a number of related considerations which had to be addressed. In the spirit which has continually driven our inquiry, the following questions emerge from current studies. What are the interrelationships between different kinds of awareness measures? What is the relationship between awareness and the ability to transfer skills which have been taught? What further strategies can be developed to facilitate transfer of learned behaviours?
A problem which persists is that of inducing and maintaining generalisation. While there is a rich emerging literature in the field of developmental disabilities pointing to the need to build generalisation strategies from the onset of treatment, a number of converging leads from other arenas might be useful. Belmont (1989) noted that strategic learning in developing children takes place by having the child assume responsibility for a trained strategy from a response to cues, to self-generated cues, to application of the strategy even when the external elements of the task change slightly. Observation of responses to instruction yield useful insights into the way this unfolds. Since much of the effects of generalisations aim for performance in naturalistic situations, insights from studies in “enactive memory” may be relevant. Koriat, Ben-Zur and Druc (1990) noted that memory for acts to be completed in naturalistic situations tend to be context-dependent. It is unclear as to whether this is because attention is diverted by contextual events, or by the fact that people’s responses are organised around their own cognitive structures leaving insufficient energy for their environments, or that motor encoding is more efficient for specific items than it is for relational information. At any rate, “enactive memory” bears resemblance to prospective memory, which has been found to be a complaint in populations of individuals with traumatic brain injury (Mateer, Sohlberg, & Crinean, 1987). This suggests that explication of “enactive” memory might be useful in providing ways of facilitating generalisation.
The study of differential impacts of instruction following procedural vs declarative training approaches also speaks to issues of generalisation. Our training included elements of both. It is apparent that individuals can talk about neglect but not carry it through in their actions. Others might show different patterns. It seems likely that such individuals might profit from different types of training.
Seemingly, at this stage in the development of treatment, the goal of neglect treatment should be to produce the habit of compensatory scanning, to provide the patient with “knowing how” to compensate for the deficit, to establish the sequence of learning-maintenance-generalisation, and to transfer the responsibility to the patient for self-cueing and self-structuring. The remediator will have to take into account that the visual information-processing component of neglect is often accompanied by disturbance in arousal, affect and awareness.
In this chapter, we have presented the results of studies which were conducted in group designs and we have tied our presentation closely to the data. However, these results are restricted in the sense that the data speak to delimited areas of transfer. Clinically, we have seen that patients who are treated for longer periods of time can translate their “knowing how” to behaviours outside of the treatment setting such as participating in cultural events and resuming employment. If this can be achieved, we have come a long way in overcoming the devastating effects of neglect on a person’s ability to function in life.
Acknowledgements
This research was supported by grants G0083000009 and H133B80028 from the US Department of Education, NIDRR, to NYU Medical Center as a Research and Training Center in Head Trauma and Stroke, and Leonard Diller, Principal Investigator.
References
Anderson, S.W. & Tranel, D. (1989). Awareness of disease states following cerebral infarction, dementia, and head trauma: Standardized assessment. Clinical Neuropsychologist. 3, 327–340.
Barco, P.B., Crosson, B., Bocosta, M.B., Werts, D., & Stout, R. (1991). Training awareness and compensation in head injury rehabilitation. In J.F. Kreutzer & P.H. Wehman (Eds), Cognitive rehabilitation for persons with traumatic brain injury. Baltimore, MD: Paul H. Brookes.
Battersby, W.S., Bender, M.D., Pollack, M., & Kahn, R.L. (1956). Unilateral partial agnosia (inattention) in patients with cerebral lesions. Brain, 79, 68–93.
Beck. A.T., Ward, J., Mendelson, M., Jock, J., & Erbaugh, J. (1961). An inventory for measuring depression. Archives of General Psychology, 4, 56–571.
Belmont, J.M. (1989). Cognitive strategies and strategic learning: The social instructional approach. American Psychologist, 44, 144–148.
Benton, A.L., Van Allen, M.W., Hammisher, K., & Levin, H.S. (1978). Test of facial recognition (Form SL). Iowa City: University of Iowa Hospitals, Department of Neurology.
Ben-Yishay, Y., Piasetsky, E., & Rattok, J. (1987). A systematic method for ameliorating disorders of attention. In M.J. Meier, A.L. Benton, & L. Diller (Eds), Neuropsychological rehabilitation. Edinburgh: Churchill-Livingstone.
Diller, L., Ben-Yishay, Y., Gerstman, L., Goodkin, R., Gordon, W.A., & Weinberg, J. (1974). Studies in cognition and rehabilitation in hemiplegia. Institute of Rehabilitation Medicine Monograph. New York: New York University Medical Center.
Diller, L., Goodgold, J., & Kay, T. (1988). Final Report to National Institute of Disability and Rehabilitation Related Research. Research and Training Center in Head Trauma and Stroke, Department of Rehabilitation Medicine, New York University Medical Center.
Diller, L. & Weinberg, J. (1968). Attention in brain damaged people. Journal of Education, 150, 20–27.
Diller, L. & Weinberg, J. (1970). Evidence for accident prone behavior in hemiplegic patients. Archives of Physical Medicine and Rehabilitation, 51, 358–363.
Diller, L. & Weinberg, J. (1977). Hemi-inattention in rehabilitation. The evolution of a rational remediation program. In E.A. Weinstein & R.P. Friedman (Eds), Advances in neurology. Vol. 18. New York: Raven Press.
Diller, L. & Weinberg, J. (1993). Response styles in perceptual retraining. In W.A. Gordon (Ed.), Advances in stroke rehabilitation. York, PA: Abington Publications.
Downey, E. (1934). The Will-Temperament Scale and its Testing. New York: World Book Co.
Egelko, S., Gordon, W.A., Hibbard, M.R., Diller, L., Lieberman, A., Holliday, R., Ragnarsson, K., Shaver, M.S., & Orazem, M.A. (1988). The relationship among CT scans, neurological exam, and neuropsychological test performance in right brain damaged patients. Journal of Clinical and Experimental Neuropsychology, 10, 539–565.
Egelko, S., Simon, D., Riley, E., Gordon, W., Ruckdeschel-Hibbard, M., & Diller, L. (1989). First year after stroke: tracking cognitive and affective deficits. Archives of Physical Medicine and Rehabilitation, 70, 297–302.
Feibel, J.H. & Springer, C.J. (1982). Depression and failure to resume social activities after stroke. Archives of Physical Medicine and Rehabilitation, 63, 276–278.
Folstein, M.P., Folstein, S.E., & McHugh, P.R. (1975). Mini mental state. Journal of Psychiatric Research, 12, 189–192.
Gianotti, G., D’Erme, P., Montebone, P., & Silveri, M.S. (1986). Mechanisms of unilateral spatial neglect in relation to laterality of lesions. Brain, 109, 599–612.
Gianutsos, R. & Matheson, P. (1987). The rehabilitation of visual perceptual disorders attributable to brain injury. In M.J. Meier, A. Benton, & L. Diller (Eds), Neuropsychological rehabilitation. London: Churchill Livingstone.
Golden, C.J. (1981). A standard version of Luria neuropsychological tests. In S. Filskov &T.J. Boll (Eds), Handbook of clinical neuropsychology. New York: John Wiley.
Gordon, W.A., Hibbard, M.R., Egelko, S., Diller, L., Shaver, M.S., Lieberman, A.L., & Ragnarsson, K.T. (1985). Perceptual remediation in patients with right brain damage: A comprehension program. Archives of Physical Medicine and Rehabilitation, 66, 353–360.
Halligan, P.W., Marshall, J.K.S., & Wade, D.T. (1990). Do visual field deficits exacerbate visual spatial neglect? Journal of Neurology, Neurosurgery and Psychiatry, 53, 487–491.
Hamilton, M. (1967). Development of a rating scale for primary depressive illness. British Journal of Social Clinical Psychology, 6, 278–296.
Heilman, K.M. (1985). Neglect and related disorders. In K.M. Heilman & E. Valenstein (Eds), Clinical neuropsychology, 2nd edn. New York: Oxford University Press.
Johnston, C. (1984). Eye movements in right brain damaged persons. Unpublished doctoral dissertation, Queen’s College, City University of New York.
Kinsbourne, M. (1977). Hemi-neglect and hemispheric rivalry. In E.A. Weinstein, R. Freidlander (Eds.) Hemi-inattention and hemispheric specialization. New York; Raven Press.
Koriat, A., Ben-Zur, H., & Druc, A. (1990). The contextualization of input and output events in memory. Haifa: Institute of Information Processing and Decision Making, University of Haifa.
Labi, M.L., Phillips, T.F., & Gresham, G. (1980). Psychosocial disability in physically restored long term stroke survivors. Archives of Physical Medicine and Rehabilitation, 61, 561–565.
Lorenze, E.J. & Cancro, R. (1962). Dysfunction in visual perception with hemiplegia: Its relation to activities of daily living. Archives of Physical Medicine and Rehabilitation, 43, 514–517.
Luria, A.R. (1961). An objective approach to the study of the abnormal child. American Journal of Orthopsychiatry, 31, 1–16.
Mateer, C.A., Sohlberg, M.M., & Crinean, J. (1987). Perceptions of memory function in individuals with closed-head injury. Journal of Head Trauma Rehabilitation, 2, 74–84.
McGlynn, S.M. & Schachter, D.L. (1989). Unawareness of deficits in neuropsychological syndromes. Journal of Clinical and Experimental Neuropsychology, 11, 143–205.
Piasetsky, E. (1981). A study of pathological assymetrics in visual spatial attention in unilaterally brain-damaged stroke patients. Dissertation Abstracts International. 42, 1213–1214.
Posner, M.I., Walker, J.A., Friedrich, F.J., & Rafal, R.O. (1984). Effects of parietal injury on covert orienting of attention. Journal of Neuroscience, 4, 1863–1874.
Powell, R., Diller, L., & Grynbaum, B. (1976). Rehabilitation performance and adjustment in stroke patients: A study of social class factor. Genetic Psychology Monographs, 93, 287–352.
Simon, D., Riley, E., Egelko, S., Newman, B., & Diller, L. (1991). A new instrument for assessing awareness of deficit in stroke patients. Poster presentation to 101st Annual Meeting of the American Psychological Association, San Francisco, CA, August.
Spreen, O. & Benton, A.L. (1969). Neurosensory center comprehensive examination for aphasia. Victoria, BC: University of Victoria, Department of Psychology.
Weinberg, J., Diller, L., Gordon, W.A., Gerstman, L., Lieberman, A., Lakin, P., Hodges, G., & Ezrachi, O. (1977). Visual scanning training effect on reading-related tasks in acquired right brain damage. Archives of Physical Medicine and Rehabilitation, 58, 479–486.
Weinberg, J., Diller, L., Gordon, W.A., Gerstman, L., Lieberman, A., Lakin, P., Hodges, G., & Ezrachi, O. (1979). Training sensory awareness and spatial organization in people with right brain damage. Archives of Physical Medicine and Rehabilitation, 60, 491–496.
Weinberg, J., Piasetsky, E., Diller, L., & Gordon, W.A. (1982). Treating perceptual organization deficits in non-neglecting RBD stroke patients. Journal of Clinical Neuropsychology, 4, 59–75.
Weinstein, E. & Kahn, R. (1955). Denial of illness. Springfield, IL: Charles C. Thomas.
Willner, A. & Strune, F. (1970). Analogy test for use with hospitalized psychiatric patients. Archives of General Psychiatry, 23, 428–437.
Zuckerman, M. & Lubin, B. (1965). Manual of multiple affect adjective check list. San Diego, CA: Educational Industrial Testing Service.