Rehab Rounds: Two Case Studies of Cognitive Adaptation Training for Outpatients With Schizophrenia

Introduction by the column editors: Psychosocial treatment and rehabilitation can be categorized as a primarily remedial or a primarily compensatory means of targeting the functional deficits of persons with schizophrenia and other disabling mental disorders. Remedial strategies attempt to overcome functional deficits by improving the individual's skills through training interventions. Social skills training and the token economy are examples of this approach (1,2). Compensatory approaches aim to create environmental supports that reduce cognitive burdens, stress, and requirements for functioning while providing for the individual's needs and quality of life. Assertive case management and supported employment are examples of compensatory programs (3,4).

Remedial interventions focus on changing the individual, while compensatory programs aim to improve support and accommodations in the person's environment. Most psychiatric rehabilitation programs, in reality, use both remedial and compensatory interventions. This month's Rehab Rounds column describes a compensatory approach called cognitive adaptation training that uses neurocognitive assessment to direct treatment planning.

Cognitive adaptation training is a series of intervention strategies designed to compensate for the cognitive impairments associated with schizophrenia and improve adaptive functioning (5). The determination of which strategies are required for a particular client is based on the results of a battery of neuropsychological tests (6), an assessment of functioning, and a structured evaluation of observed behavior.

The neuropsychological tests used in the approach are described in Table 1. They are usually administered by master's-level psychologists, and the results are given to therapists in the cognitive adaptation training program for treatment planning. Program therapists can be from any mental health discipline, including psychology, social work, occupational therapy, and nursing, and may have an educational background ranging from high school through doctoral-level professional training.

The assessment of functioning, completed by the program therapist, is based on use of the Functional Needs Assessment, a 26-item performance-based measure of the client's ability to initiate and perform basic activities of daily living (7). This instrument covers multiple areas of adaptive functioning such as grooming, avoiding hazards, shopping, and care of belongings. Scores obtained during a structured, clinic-based assessment are supplemented with results of assessments done during home visits. Thus scores on the Functional Needs Assessment reflect actual performance in the home. For example, if a home visit reveals that a client's clothes are not clean, the scores for structured performance on items of the Functional Needs Assessment that reflect dressing and laundry skills may be amended.

During home visits, the therapist from the cognitive adaptation training program also thoroughly assesses the client's living environment to identify safety hazards such as improper storage of foods—for example, flour kept next to rat poison and inappropriate use of electrical appliances, such as using a space heater to boil water or using appliances with frayed electrical cords. In addition, the therapist checks the availability of necessary supplies, such as a toothbrush and laundry soap, and determines if they are properly placed. The therapist also characterizes the natural support systems that are available to the person, including the level of structure provided in the home, the tasks that are done for the client, and the degree to which parents or residential staff are knowledgeable about mental illness.

Finally, the therapist completes the Frontal Lobe Personality Scale (Grace J, Malloy P, unpublished manuscript, 1992) based on behavior observed before the client's discharge from the hospital and during home visits. This scale was designed to quantify behavioral syndromes that have been associated in theory with abnormalities in various frontal circuits. For example, abnormalities in the anterior cingulate cortex and lateral orbital prefrontal cortex have been associated with apathy and disinhibition, respectively.

The scale contains 46 items focused on the frequency with which clients show interest in tasks, neglect tasks, behave inappropriately or impulsively, become stuck on certain ideas, and become cognitively derailed while performing a task. Scores are converted into T-score form. Based on an algorithm of scores, individuals are classified as apathetic, disinhibited, or mixed. Roughly one-third of all outpatients we have tested fit into each of these categories.

Individuals with primarily apathetic behavior tend to have poverty of speech and action and to be unable to initiate and follow through on behavioral sequences. Individuals scoring higher on disinhibition tend to be distractible, too easily driven by cues in the environment, and lacking in judgment (8). Those with a mixed profile have a combination of these behavioral tendencies, which can be observed in many areas of instrumental behavior. Table 2 provides an example of each these profiles related to dressing.

Although the same overt behavior, such as skipping steps in dressing, may occur due to apathy (not being able to initiate behavioral sequences) or to disinhibition (being distracted during the task), scores on the Frontal Lobe Personality Scale allow clinicians to identify the underlying styles that lead to similar overt behaviors. Moreover, the overt behaviors and symptoms of schizophrenia only partly overlap. Among participants in our program, correlations between apathy and negative symptoms range from .30 to .59 (Pearson correlation coefficient), and those between disorganization symptoms and disinhibition range from .33 to .43.

In the same way that assessments such as the Brief Psychiatric Rating Scale characterize symptoms with well-defined anchor points, the Frontal Lobe Personality Scale characterizes an individual's approach to goal-directed activity. Classifications of clients' behaviors tend to remain stable over a three- to six-month period and correlate more highly with multiple measures of community outcome than do ratings of symptoms.

Both level of impairment on measures of executive functioning and overt behavior guide the types of compensatory strategies applied in cognitive adaptation training. In general, clients with greater degrees of executive impairment need a greater level of structure and assistance and also need larger, brighter, and more proximally placed visual cues to remind them of appropriate behavior. Individuals with less impairment in executive function can perform instrumental skills adequately with less structure and more subtle cues. Often clients who show apathy need prompting and cueing to complete each step in a sequenced task. Clients with disinhibited behavior respond well to the removal of distracting stimuli and to redirection. Those with mixed profiles benefit from a combination of these approaches.

Interventions may be adapted for significant memory, attention, and fine motor impairments or strengths. For example, changing the color or placement of signs may help capture the client's attention. Similarly, substituting Velcro fasteners for buttons may compensate for a client's impairment in the fine motor coordination needed for dressing.

The following two cases differ in the client's level of executive impairment, in the types of overt behavior shown, and in the range of compensatory strategies used in the client's cognitive adaptation training. The cases were drawn from among subjects participating in research on the use of compensatory strategies at the clinical research unit of San Antonio State Hospital during 1995 to 1997. Since 1993, as part of ongoing studies, about 100 clients have participated in the cognitive adaptation training program.