Cognitive Remediation Program for Young Cancer Patients Stresses Skills Acquisition

BUFFALO, NY--A cognitive remediation program that stresses skillsacquisition rather than reiterative practice may improve attentionand concentration deficits in cognitively impaired survivors ofchildhood cancer, Robert W. Butler, PhD, reported at the FourthInternational Conference on Long-Term Complications of Treatmentof Children and Adolescents for Cancer.

The conference, hosted by Roswell Park Cancer Institute, was co-sponsoredby the Bristol-Myers Squibb Oncology Division and the NCI.

"Attentional dysfunction is one of the most common neurocognitiveside effects of cranial irradiation and several chemotherapies,and negatively affects a child's quality of life and academicachievement," said Dr. Butler, a researcher at the ChildDevelopment & Rehabilitation Center, Oregon Health SciencesUniversity, Portland.

For the past several years, Dr. Butler and his colleagues havebeen developing and pilot testing cognitive remediation programsto improve attention/concentration, nonverbal reasoning, and spatialprocessing in children whose cancer or treatment has affectedthe central nervous system.

The result is a cognitive remediation model that emphasizes skillsacquisition and deemphasizes (but includes) the more traditional"Practice! Practice! Practice!" component.

The model integrates psychotherapy (to address quality of lifeissues) and multisensory modality instruction (to improve academicperformance, particularly in arithmetic). Overarching this modelis a strong support network of parents, teachers, and therapists.

Saturation training with massed practice has been used with partialsuccess in adult remediation programs, but its usefulness in childrenhad been largely untested, said Dr. Butler, who discovered earlyon that this model would need to be "reconceptualized"before adapting it a younger population. "Pilot testing suggestedthat massed practice alone provided few benefits in children,"he said.

In the Oregon model, each child works on activities designed tostrengthen attentional, perceptual, and nonverbal cognitive processes,while a therapist observes the child's approach to the task.

"Ineffective strategies are identified and new approachesare taught," Dr. Butler said. These new strategies may includepsychological preparedness ("We tell the kids: Psych yourselfup for success") and organization of and a thorough familiaritywith the task materials. Children are strongly encouraged to periodicallycheck their performance, refrain from self-distracting behavior,such as worrying, and set personal goals.

Adapting Skills to the Real World

Children receive individualized cognitive-behavioral therapy toreinforce their ability to ignore and withstand distraction, andto enhance self-esteem. A series of activities using fractions,manip-ulatives, and visual-spatial puzzles, is administered topromote arithmetic concept development.

Although the acquisition of attentional skills and new learningstrategies drives this model, the practice of cognitive skillsplays an essential supportive role "in helping improve thebrain's ability to rapidly process information," he said.

Dr. Butler also pointed out that parents and teachers have beenkey to the program and help children successfully apply what theylearn in therapy to the real world. "We meet with teachersthree times during therapy, and they have been very receptive,"he said. "Children bring homework into therapy, and the activeuse of new, more effective strategies is closely monitored andencouraged both at home and in school."

Remediation programs run a "manageable" 6 months withone 2-hour session per week, thus, minimizing school absencesdue to therapy. The program is transportable to other institutionswith minimal staff training. Materials are readily available fromnational distributors, and a detailed instruction manual has beendeveloped.

While the cognitive remediation program does not eliminate cognitiveimpairment, preliminary results do suggest improvement in attention/concentrationskills and arithmetic performance in most patients.

"One subject, for example, was moderately to markedly impairedprior to entering our program," Dr. Butler said. "Aftertreatment, he was generally within normal limits and gained 1½to 2 grade levels in arithmetic skills."

Dr. Butler noted that the model will require continual revisionto improve its effectiveness, but he believes that the programis ready for testing in a phase II clinical trial.