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«Cognitus & Moi»: A Computer-Based Cognitive Remediation Program for Children with Intellectual Disability

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Attentional, visuospatial, and social cognition deficits have a negative impact on children's adaptative and social competences and, as a result, on their ability to achieve a normal functioning and behavior. Until now and despite the frequency of those deficits, there is a lack of children's specific cognitive remediation tools specifically dedicated to attentional and visuospatial areas. The «Cognitus & Moi» program involves a variety of exercises in a paper and/or pencil (n = 30) or a computerized format (n = 29) and a strategy coaching approach. Each module of «Cognitus & Moi» targets a single impaired cognitive area, within the limits of cognitive domains' overlapping. The little cartoon character named Cognitus, who illustrates the program, is supposed to be very friendly and kind toward children. Cognitus will accompany them throughout the program for an effective and positive reinforcement. The main goal of «Cognitus & Moi» is to adjust to children's difficulties in daily life. Moreover, since the cognitive remediation benefit is complex to apply in daily life, the program is based on a metacognitive strategy. After a complete neuropsychological assessment and a psychoeducational session (with the child and the parents), 16 1-h-sessions of cognitive remediation with the therapist are proposed. Each session is composed of three parts: (1) computerized tasks focusing on specific attentional or visuospatial components (20 min). The attentional module targets hearing, visual, and divided attention. A double attention task is also proposed. The visuospatial module targets eye tracking and gaze direction, spatial orientation, visuospatial memory and construction, and mental imagery; (2) pen and paper tasks focusing on the same processes (20 min) and a facial emotion recognition task; (3) a proposal of a home-based task (during 20 min). Weekly, specific attentional and visuospatial home tasks are proposed to the child and analyzed with the parents and the therapist. Indeed, home exercises are useful to promote the transfer of strategies to daily life and their subsequent automation. The heterogeneity of cognitive deficits in intellectual deficiency necessitates an individualized cognitive remediation therapy. In this regard, «Cognitus & Moi» seems to be a promising tool.
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February 2016 | Volume 7 | Article 101
TECHNOLOGY REPORT
published: 03 February 2016
doi: 10.3389/fpsyt.2016.00010
Frontiers in Psychiatry | www.frontiersin.org
Edited by:
Jérôme Favrod,
University of Applied Sciences and
Arts of Western Switzerland,
Switzerland
Reviewed by:
Laurent Lecardeur,
CHU de Caen, France
Caroline Vandeleur,
Lausanne University Hospital,
Switzerland
*Correspondence:
Caroline Demily
caroline.demily@ch-le-vinatier.fr
Specialty section:
This article was submitted to Public
Mental Health,
a section of the journal
Frontiers in Psychiatry
Received: 03December2015
Accepted: 18January2016
Published: 03February2016
Citation:
DemilyC, RigardC, PeyrouxE,
Chesnoy-ServaninG, MorelA and
FranckN (2016) «Cognitus & Moi»: A
Computer-Based Cognitive
Remediation Program for Children
with Intellectual Disability.
Front. Psychiatry 7:10.
doi: 10.3389/fpsyt.2016.00010
«Cognitus & Moi»: A Computer-Based
Cognitive Remediation Program for
Children with Intellectual Disability
Caroline Demily1,2* , Caroline Rigard1,2 , Elodie Peyroux1,2,3 , Gabrielle Chesnoy-Servanin4 ,
Aurore Morel1,2 and Nicolas Franck2,3
1 GénoPsy, Center for the Diagnosis and Management of Genetic Psychiatric Disorders, CH Le Vinatier, Bron, France, 2 UMR
5229, EDR-Psy, Center of Cognitive Neuroscience, CNRS, University Lyon 1, Lyon, France, 3 Centre référent lyonnais en
réhabilitation psychosociale et en remédiation cognitive (CL3R), CH Le Vinatier, Bron, France, 4 Unité de Psychoéducation
Polaire, Centre Hospitalier le Vinatier, Bron, France
Attentional, visuospatial, and social cognition decits have a negative impact on chil-
dren’s adaptative and social competences and, as a result, on their ability to achieve a
normal functioning and behavior. Until now and despite the frequency of those decits,
there is a lack of children’s specic cognitive remediation tools specically dedicated
to attentional and visuospatial areas. The «Cognitus & Moi» program involves a variety
of exercises in a paper and/or pencil (n=30) or a computerized format (n=29) and a
strategy coaching approach. Each module of «Cognitus & Moi» targets a single impaired
cognitive area, within the limits of cognitive domains’ overlapping. The little cartoon
character named Cognitus, who illustrates the program, is supposed to be very friendly
and kind toward children. Cognitus will accompany them throughout the program for
an effective and positive reinforcement. The main goal of «Cognitus & Moi» is to adjust
to children’s difculties in daily life. Moreover, since the cognitive remediation benet is
complex to apply in daily life, the program is based on a metacognitive strategy. After
a complete neuropsychological assessment and a psychoeducational session (with the
child and the parents), 16 1-h-sessions of cognitive remediation with the therapist are
proposed. Each session is composed of three parts: (1) computerized tasks focusing on
specic attentional or visuospatial components (20min). The attentional module targets
hearing, visual, and divided attention. A double attention task is also proposed. The
visuospatial module targets eye tracking and gaze direction, spatial orientation, visuo-
spatial memory and construction, and mental imagery; (2) pen and paper tasks focusing
on the same processes (20min) and a facial emotion recognition task; (3) a proposal of
a home-based task (during 20min). Weekly, specic attentional and visuospatial home
tasks are proposed to the child and analyzed with the parents and the therapist. Indeed,
home exercises are useful to promote the transfer of strategies to daily life and their
subsequent automation. The heterogeneity of cognitive decits in intellectual deciency
necessitates an individualized cognitive remediation therapy. In this regard, «Cognitus &
Moi» seems to be a promising tool.
Keywords: attention, visuospatial functions, social cognition, cognitive remediation, intellectual disability,
behavior, hyperactivity
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WHY SHOULD WE CONSIDER COGNITIVE
REMEDIATION FOR PEOPLE WITH
INTELLECTUAL DISABILITY?
Denition and Functional Outcome
In most classications, such as the DSM-5 (1), intellectual disabil-
ity is dened as a decit of cognitive abilities such as reasoning,
problem solving, planning, abstract thinking, judging, academic
learning, and learning by experience. However, other cognitive
dysfunctions are associated with intellectual disability. Actually,
attentional (2), memory (3), visuospatial (4), and executive (57)
alterations are also found.
All these can be associated with an impairment of adaptive
functioning. is impairment prevents people from being
independent and socially responsible and appears during the
development stages. Research on the functional and concrete
impact of these cognitive decits is currently being structured
and developed. As an example, Berg (8) and Bull and Scerif (9)
have shown that the mathematical diculties encountered by
children with intellectual disabilities are due to their low work-
ing memory capacities and to an executive dysfunction. In eect,
working memory and short-term memory play a major role in a
number of daily activities (10) because they help maintain and
control information in memory (11). us, we may conclude that
cognitive decits are closely related to the functional outcome.
e care of people with intellectual disability is a public health
issue, 1–3% of the population being concerned (12). Speech
therapy and psychomotor care are well-developed for children
with intellectual disability (13). ese techniques mainly help
these people develop their communication and motor skills. Since
cognitive functions other than language (14, 15) and psychomo-
tor abilities are impaired in children, as well as adults, it seems
interesting to consider the development of specic cognitive
remediation programs.
Denition of Cognitive Remediation
Cognitive remediation is a behavioral training aiming at mini-
mizing the daily impact of cognitive decits by optimizing and
improving cognitive functioning (16). In this regard, the notion
of functional adaptation should be highlighted. In this connec-
tion, cognitive remediation has been dened as psychological
treatment aimed at “increasing the general cognitive eciency to
improve global adaptation, independence, and well-being.
e development of new strategies and tasks can be used to
improve cognitive functioning. In the eld of intellectual disabil-
ity, two theories explain the eectiveness of cognitive remediation.
e rst one is based on a developmental approach (17).
People with intellectual disability follow the same develop-
ment as people without but at a slower pace. In this case,
cognitive remediation is used to acquire the main skills such
as categorization, spatial relations, and the numbering and
ordering concepts.
e second theory is based on a modular conception of cogni-
tion (18). People with intellectual disability present various
cognitive proles: preserved skills as well as decits can be
observed. Dierences depend on the origin of the decit. For
example, diverse cognitive proles can be observed accord-
ing to the genetic conditions (Williams syndrome, Down
syndrome, or X-Fragile syndrome) (5, 19). ose data have
mainly been shown in the eld of memory (20). In this case,
cognitive remediation can help develop strategies to improve
impaired cognitive processes. e «Cognitus & Moi» program
is based on this conception.
COGNITIVE REMEDIATION OF CHILDREN
AFFECTED BY INTELLECTUAL
DISABILITIES: THE DIFFERENT
PROGRAMS
Concerning intellectual disability, cognitive remediation pro-
grams must be based on some general principles. ey should
be clearly dened before beginning the treatment. e therapist
ought to set objectives according to the child’s practical needs.
Improvement of cognitive functions will enable the child to reach
his/her goals.
Memory Programs
Cognitive remediation focused on short-term memory has been
well studied. Hulme and Mackenzie (21) worked on articulatory
recapitulation strategy using a cumulative repetition method. It
consisted of ten 10-min sessions. is program was carried out
with teenagers (13–18years old) aected by intellectual dis-
abilities. e authors showed a signicant improvement of the
memory span. en, Comblain (22) enhanced this program by
proposing 30-min individual weekly training sessions (growing
diculty) with subjects (n=12) aected by Down syndrome.
is study showed a signicant improvement of the average
memory span. Moreover, long-term eects were also observed
18months later. With this strategic approach, Bussy etal. (23)
demonstrated an extension of the verbal span and a growing
passive vocabulary. Finally, improvements were observed in the
verbal short-term memory of 33 children suering from fetal
alcohol syndrome (24).
In the eld of meta-memory, Kendall etal. (25) have shown
that children with intellectual disability are able to learn an inter-
rogative strategy encouraging them to nd links between dier-
ent stimuli. is group showed higher scores than the control one
as far as recalling items were concerned.
Metacognitive Program
Découvrez vos capacités, rEalisez vos possibilités, pLaniez votre
démarche, soyez créatiFs (DELF) is a metacognitive program,
which aims at discovering the subjects skills and highlighting
the persons abilities. is program is used in groups and aims
at teaching metacognitive strategies (anticipation, planning, and
control) and more specic strategies helping, for example: to better
use working memory so as not to overload memory. DELF proved
to be eective with teenagers suering from intellectual disability
when associated with a regular teaching program (26). Within this
experimental group, inductive thinking abilities were improved.
TABLE 1 | «Cognitus & Moi»: attentional and visuospatial modules.
Attention Visuospatial
Hearing attention Eye tracking/gaze direction
Visual attention Spatial orientation
Divided attention Visuospatial memory
Double attentional tasks Mental imagery
Visuospatial construction
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Virtual Reality
Few studies focus on the use of virtual reality for the treatment of
people with intellectual disabilities (27). Rose etal. (28) pointed
out the relevance of an active exploration in a virtual environment
with the use of a joystick rather than a passive exploration thanks
to a mere observation. Handling a joystick enabled the subjects
to better memorize the environment visuospatial data. us,
development of virtual reality programs would enable patients to
improve their visuospatial abilities.
Attentional Program
Galbiati etal. (29) proposed treatment for children and teenagers
aged 6–18years, presenting traumatic brain injury combined
with a mild intellectual disability and attentional diculties. e
program used targeted attentional abilities by using metacognitive
strategies. Treatment lasted for 6months, including four 45-min
individual weekly sessions led by a therapist. During the sessions,
30min were dedicated to computerized exercises and 15min to
paper/pencil exercises. e participants’ attention resources and
adaptive skills improved on a daily basis.
VISUOSPATIAL SKILLS AND SOCIAL
COGNITION IN INTELLECTUAL
DISABILITY
Visuospatial ability refers to the capacity to identify visual and
spatial relationships among objects. How subjects imagine objects,
perceive global shapes, and how they locate small components
or understand the similarities and dierences among objects are
major cognitive functions.
Visuospatial and visuoperceptual skills play a key role in
everyday life. Visual information and complex visual stimuli are
analyzed with a complete unawareness of the visuoperceptual
process or the complexities of the stimuli involved. is process
becomes conscious in a context of learning. Repetition and
familiarity enable a more spontaneous approach and turn the
conscious and eortful process into an automatic one.
If this ability is impaired, many types of decits can occur,
ranking from a failure to process the basic elements of a visual
stimulus (i.e., colors, lines, orientation) to more complex and
integrative features such as object identication, faces, or familiar
scenes. ese decits can include social cognition defects, espe-
cially in the area of facial emotion recognition.
Social cognition is a psychological construction referring
to the understanding of others’ thoughts and including several
components such as empathy, attribution bias, theory of mind,
and emotion processing. Impairments in this eld may largely
underlie social dysfunctions and reduce adaptive skills. Moreover,
social cognitive disabilities contribute more or less directly to
behavioral disturbances and psychiatric symptoms (e.g., depres-
sion, anxiety) (30). Yet, depressive and anxious symptoms are
oen found in children with intellectual disabilities (31, 32). In
this regard, a link is clearly established between children’s lan-
guage and behavioral impairments when it comes to intellectual
disability (33). Behavioral and psychiatric symptoms are also
correlated to intellectual disability in adults, as shown by Deb
etal. (34).
Children with externalizing behavioral problems provide
aggressive responses to hypothetical vignettes more spontane-
ously than children with intellectual disability without any
behavioral problems (35). Cognitive dysfunctions explain the
hardship children encounter in the treatment of social infor-
mation (36). Indeed, social cognition dysfunction appears like
a core symptom (37). e theory of mind and facial emotion
recognition seem to be central for social adaptation to the envi-
ronment (38).
As far as social cognition is concerned, the facial emotion
recognition is well documented. Children with intellectual dis-
ability fail to recognize and match emotional facial expressions
from a series of photographs depicting various facial expressions
(39). is decit is correlated with an abnormal behavior (40) and
underlain by visuospatial and attentional decits (41).
In conclusion, the improvement of attentional and visuospatial
decits thanks to a specic cognitive remediation program could
have a positive impact on the children’s social cognition and
behavior. is approach would complete the methods already
available.
THE «COGNITUS & MOI» PROGRAM
Attention, visuospatial, and social cognition decits have a nega-
tive impact on children’s adaptive and social competences and,
as a result, on their ability to achieve normal functioning and
behavior. Until now and despite the frequency of those decits,
there is a lack of children’s specic cognitive remediation tools
specically dedicated to attentional and visuospatial areas.
e «Cognitus & Moi» program targets attentional and visu-
ospatial functions (Table1). Cognitive goals are embedded in
two dierent modules (attention and visuospatial) and the level
of these modules is chosen according to the child’s key dicul-
ties. Each exercice of «Cognitus & Moi» targets a single-impaired
cognitive area.
«Cognitus & Moi» was developed in France through the col-
laboration between the GénoPsy center (Center for the Detection
and Management of Psychiatric Genetic Disorders) in Lyon, the
EDR-Psy research team (CNRS & Lyon 1 University, headed by Pr.
Nicolas Franck) and the SBT Company (headed by Pr. F. Tarpin-
Bernard). e Génopsy team examines patients who suer from
psychiatric genetic disorders. us, neurocognition, social cogni-
tion, as well as metacognition are routinely evaluated. e SBT
Company and the EDR-Psy team have already developed various
cognitive remediation programs (RECOS, GAIA, RC2S) (42, 43).
TABLE 3 | Neuropsychological assessment.
Domains Tests Targeted functions
Cognitive
performances
WPPSI III (56) or WISC IV (57) Intellectual abilities
Language Peabody Picture Vocabulary
Test-R (58)
Passive vocabulary
Praxis Imitating hand positionsNEPSY II
[(59, 60); French adaptation: ECPA]
Gestural praxis
Visuospatial
processing
Visuomotor precisionNEPSY II Oculomotor
coordination
Sky searchTEA-Ch (61) Visual search/spatial
selective attention
Arrows – NEPSY II Judgment of line
orientation
Block construction – NEPSY II Visuospatial
construction
Route nding – NEPSY II Visuospatial interactions
Memory Word listsCMS [(62); French
adaptation: centre de psychologie
appliquée]
Verbal memory
Dot locationsCMS Spatial memory
Attention AlertnesskiTAP Vigilance/visual
attention
Auditory attention and response set
part 1NEPSY II
Selective auditory
attention
Divided attentionkiTAP/TAP Divided attention
Executive
functions
Go/NoGokiTAP (63)/TAP [(64);
French adaptation: Leclercq M.]
Motor inhibition
Auditory attention and response set
part 2NEPSY II
Cognitive inhibition and
cognitive exibility
InhibitionNEPSY II Cognitive inhibition
LabyrinthsWISC III Visuospatial planning
Social
cognition
Theory of mindNEPSY II Theory of Mind
Affect recognitionNEPSY II Facial affect recognition
CMS, Children’s Memory Scale; NEPSY II, Developmental NEuroPSYchological
Assessment (second edition); TAP/kiTAP, test battery of attention performance;
WISC IV, Wechsler Intelligence Scale for Children (fourth edition); WPPSI III, Wechsler
Preschool and Primary Scale of Intelligence (third edition).
TABLE 2 | Keys of the program.
«COGNITUS & MOI»: main principles
Intensive and targeted cognitive training
Therapist and child relationships: interactive process
Learning modalities:
Active processing in addition to practice
Verbal mediation techniques,
Training of processes implied in attentional and visuospatial functions
Selecting relevant information
Concrete goals
Content: 2 independent elds (attentional and visuospatial processes)
totalizing 29 exercises
Modalities: paper and pencil+computerized training
A collaborative therapy: development of child’s own strategies
Target: selective attentional and visuospatial impairments
Adaptability: nine levels of difculty for each exercise
Exercises adapted to each child’s capacities including a positive
reinforcement
Exercises with parents at home (supervised by the therapist)
Psychoeducation: for both the child and his/her parents at the beginning
ofthetherapy
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All the developers implicated in «Cognitus & Moi» are
trained therapists for cognitive remediation. e exercises of the
attentional and visuospatial modules were selected in the SBT
soware database. First, the selected exercises were proposed to
children with normal cognitive functioning in order to appreciate
the technical feasibility. Second, each exercise was adapted (levels
one to nine) in order to be proposed to children with intellectual
disability. e third step was the development of a facial emotion
recognition task. Each Cognitus’ facial expression was based on
the Ekman pictures (Appendix 4 in Supplementary Material) with
three levels of intensity (44).
«Cognitus & Moi» e «Cognitus & Moi» program involves
a variety of exercises in a paper and/or pencil (n=30) or a
computerized format (n=29) and a strategy coaching approach.
erapists make use of techniques known to benet the rehabili-
tation of cognitive syndromes.
is new cognitive remediation program was elaborated with
two main goals in mind. e rst one aimed at adjusting to the
childrens diculties in daily life. In order to achieve this purpose,
we developed an individualized and exible program meant to
improve both specic attentional and visuospatial impairments
and to reach each child’s concrete objectives. Since the cognitive
remediation benet is complex to apply in daily life, a program
based on collaboration with parents was elaborated (Table2).
«Cognitus & Moi» is designed for 5–13-year-old children with
or without intellectual deciency. e little cartoon character
named Cognitus, who illustrates the program, is supposed to be
very friendly and kind toward children. Cognitus will accom-
pany them throughout the program for an eective and positive
reinforcement.
Cognitive Assessment
A complete and detailed neuropsychological assessment prior to
the cognitive remediation treatment seems necessary (45). is
evaluation will also determine the severity of the impairments
and their impact on everyday life. Currently, consensus lacks con-
cerning attentional and visuospatial evaluations, so they reect
the heterogeneity of the performances.
is assessment must help establish the global degree of
intellectual disability by using standardized tools such as the
Wechsler scales. en it is important to assess the functional
level of the person by using more specic tools such as the
Vineland Adaptative Behavior Scale, second Edition [VABS-II
(46)], the EFI [Functional Intervention Scale (47)] or the AAPEP
[Psycho-educative prole for adolescents and adults (48)]. In
intellectual disability, the IQ is most oen evaluated without a
thorough evaluation of the dierent cognitive domains. However,
a detailed cognitive assessment is necessary to establish a detailed
neuropsychological prole by identifying the cognitive impair-
ments and also the preserved abilities of the person.
e following assessment is recommended (before the
«Cognitus & Moi» program): (Table3).
Preliminary Session: Psychoeducation
In the rst part of this session, the therapist, the parents and
the child go through the previously administered assessment
together. By explaining the child’s cognitive assessment to the
TABLE 4 | Computer-based modules.
For example: visual attention
“Looking for”:
selective attention,
visual exploration and
discrimination
Several identical symbols
are hided in a photography.
The child has to observe
the image and to locate the
symbols. The complexity of
the task increases according
to the determined level (one
to nine).
“The differences”:
selective attention,
visual exploration and
discrimination
A child, with the help of a
therapist, will determine the
difference between the two
sides of the presentation.
He/She will have to nd
which image appears on the
right but not on the left. The
child should use a specic
strategy to answer properly.
TABLE 5 | Pen-and-paper based modules.
The child has to follow
and color the link between
the characters and the
balloons
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parents helps them better understand his/her prole, and which
of his/her cognitive components are impaired and which are
preserved. at is the reason why this session lays emphasis upon
the specic impairment in the child’s daily life.
e last session of the preparation phase provides psychoe-
ducation via two specic documents. A specic comic strip has
been elaborated for children explaining the main goals of atten-
tional and visuospatial functions (Appendix 1 in Supplementary
Material). Moreover, a didactic document «Parent handbook» is
proposed to the parents in order to detail the attentional and visu-
ospatial functions and the «Cognitus & Moi» program (Appendix
2 in Supplementary Material).
e aim of the psychoeducational session is to allow the child
and his/her parents to understand the specic terms used in the
eld of neurocognition, their implication in daily life, to nally
increase motivation.
Cognitive Remediation Sessions
withtheTherapist
en, 16 1-h-sessions of cognitive remediation with the therapist
are proposed, each session is composed of three parts:
(1) pen and paper tasks focusing on specic attentional or visu-
ospatial component (20min),
(2) computerized tasks focusing on the same process (20min),
(3) a proposal of a home-based task (during 20min).
Each of the 16 sessions deals with a specic attentional and
visuospatial stimulation. e computer-based tasks are ranked in
increasing order of diculty, with nine levels of complexity. is
allows the therapist to adapt diculty of exercises to the child’s
abilities.
Design of the Computer-Based Modules
(n=29) (Table 4)
Design of the Pen-and-Paper Based
Modules (Table 5)
Similarly, pen-and-paper exercises will help the child to develop
compensatory strategies when it comes to visuospatial or atten-
tional tasks. Adapting the rhythm of the treatment to the child’s
abilities helps prevent him/her being faced to failures. e rhythm
is progressive, as must be the diculty of each exercise.
Finally, the child will have to recognize Cognitus’ facial emo-
tion (Appendix 4 in Supplementary Material) with the help of
the therapist. is exercise was developed in order to establish a
concrete link between visuospatial functions and facial emotion
recognition. e drawings are designed in order to encourage the
person to focus on the eyes. People with intellectual disabilities
oen study the mouth area to recognize emotions. e strategy
developed in this tool will help children determine an emotion
by using relevant information. By highlighting the eye area, the
strategy can be automated by the child. He/She has to choose the
correct emotional label by verbalizing the name of the emotion.
Six universal emotions are represented (without neutral condi-
tion): happiness, fear, anger, disgust, surprise, and disgust.
Therapist’s Strategies in «Cognitus & Moi»
Mediation by a therapist is one of the key factors to the success
of psychological treatment. Individual care helps maintain the
collaboration over time between the child and the therapist.
Verbalization plays an active part in the training of a new strategy.
e therapist helps the child nd sense when a problematic situa-
tion arises. e development of the new skills will be transferred
to daily life. e therapist should encourage the child to actively
take part in the treatment by choosing his/her own program of
exercises and goals.
e structuration of the sessions is required in order to help
the child deal with the notion of delay and waiting. is can be
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done by presenting the program of each session at the beginning
and by estimating the time to be spent on each task. Aer each
task, the therapist will remark on the time spent on the exercise
to improve the perception of chronological indicators.
is technique is detailed in dierent steps in «Cognitus &
Moi», in order to automatize and generalize the new strategies.
First, the therapist describes out loud the dierent steps com-
posing the used strategy.
en, it is up to the child to describe these steps out loud.
Finally, the child must be able to internalize these steps with-
out the help of the therapist.
Children with an intellectual disability will nd it easier to
transfer memory strategies to daily life when it has been explicitly
verbalized during the cognitive remediation sessions (49).
Home Task with the Parents
e cognitive remediation session with the therapist nishes with
a proposal of a home task. Exercises take into account both the
level of performance of the child, the collaboration of the parents,
and are related to the concrete objectives dened at the beginning
of the therapy.
e outstanding idea of the program is to establish a weekly link
between cognitive remediation and daily life. Moreover, we will
help the child understand his/her environment using colors and
time landmarks. Tasks are adapted to the child’s needs and take
into account his/her daily reality. For example, at the beginning
of the therapy, it could be suggested that the child should shop
at the local supermarket and nd a given item in a department.
Later, specic attentional and visuospatial home tasks can
be proposed to the child and analyzed with the parents and the
therapist. Finally, tasks such as the planning of a daily route can
be suggested. Home exercises are useful to promote the transfer
of strategies to daily life and their subsequent automation. is is
consistent with learning theories. Indeed when cognitive reme-
diation is reinforced in real-world settings, the learning process
is facilitated and then generalization and transfer are promoted
(50). e child and the therapist will go through the home task
together at the beginning of the next remediation session. In order
to promote motivation during the home task, the use of a person-
alized exercise book allows a concrete weekly evaluation of the
degree of achievement of the task. e child can self-evaluate his/
her performances with a smiley, in the same way, his/her parents
can also evaluate their child by answering four concrete questions:
1. Did your child complete the activity?
2. How did your child nd the activity?
3. How did your child behave during the activity?
4. Was the goal of the activity clear to you?
METACOGNITIVE ASPECTS AND
BENEFITS
People with intellectual disabilities have diculties in tasks
requiring a voluntary eort and a conscious analysis of the cog-
nitive demands of the task. is diculty prevents the subjects
from spontaneously engaging themselves in a task when this one
requires a strategic active treatment.
Metacognition corresponds to the knowledge of ones own
functioning. e metacognitive processes are procedural apti-
tudes that have an impact on the cognitive aims of the person and
on the tasks carried out. In this regard, positive reinforcement
represents a key to success.
In our program, Cognitus the little character, kindly supports
the child (Appendix 3 in Supplementary Material). Moreover,
the parents’ cooperation plays a key role. at is the reason why,
«Cognitus & Moi» is clearly distinguished from the daily home-
work to avoid conicts.
Only few patients with intellectual disabilities manage to nd
work or live alone; however, families hope that close relatives will
be able to be more independent (27). is is why the ultimate aim
of a cognitive remediation program is to improve the subject’s
quality of life. is has to be done by acquiring new strategies
that will help the patient achieve the exercises and then generalize
the strategies and benets. e idea is to apply a learned strategy
to a more global context, distant from the initial one. People
with intellectual disabilities are described as cognitively passive
(51). is is characterized by a lack of strategy transfer (52). It is
particularly complicated to obtain transfer; each strategy taught
has a dierent adaptive value depending on the environment and
on the needs of the person (53). It is important to rst acquire
the skills before trying to contextualize them in more complex
environments. e therapist will help systematically to establish
the link between the skills acquired during the sessions and situ-
ations of daily life by using, for example, home tasks. ese tasks
should rst be dened with the patient during the sessions and a
feed-back will then be given during the following session.
In general, children with intellectual disabilities have a
sense of failure and the feeling of being incompetent. Cognitive
remediation helps the child escape this negative spiral. Positive
reinforcement and mediation by a therapist in the «Cognitus &
Moi» program have an impact on the child’s condence in his/
her abilities and thus on self-esteem. In this regard, the child is
the winner of an award aer the cognitive remediation training
(Appendix 3 in Supplementary Material).
Self-determination is the possibility for the person to choose
his/her own activities and behaviors (54). e therapist plays an
important part in the improvement of self-determination. By
reinforcing the child’s feeling of competence (positive feedback)
and by choosing adapted exercises (nor too easy, nor too dicult)
the therapist improves self-condence (55).
VALIDATION STUDY
e cognitive decits presented by patients with intellectual
disability are very diverse. Yet, most studies on the eectiveness
of cognitive remediation treatment are randomized controlled
trials, especially in the area of mental health and education.
Randomized controlled trials have been used to evaluate a num-
ber of educational interventions but remain less frequent in the
cognitive remediation area.
We are currently conducting (preliminary steps) a randomized
controlled trial in order to establish the validity of the «Cognitus
February 2016 | Vol ume 7 | Article 107
Demily et al.
Cognitus & Moi
Frontiers in Psychiatry | www.frontiersin.org
& Moi» program. All the ethical approval (French legislation) is
in process (CPP, CCTIRS, CNIL, and Clinical trials.gov registra-
tion). Our rst objective is to evaluate the impact of the program
on behavioral disorders. A thorough assessment is proposed
including a complete evaluation of the components of neurocog-
nition, social cognition, and of social functioning and behavior.
ese measures and the complete assessment are repeated at the
end of the intervention to highlight the impact of the «Cognitus
and Me» program, and 6months later to investigate the possible
long-lasting eects of the benets. Currently, the rst children
are following the therapy with the «Cognitus and Me» program
in a context of usual care. e exercises appear very close to daily
life and very pleasant. Another point is the parents’ wishes to be
involved in their child’s therapy. In this regard, the program meets
their expectations.
However, our program presents several limits. First, only the
attentional and visuospatial decits as well as emotion recogni-
tion are targeted. Other cognitive dysfunctions are associated
with intellectual disability, especially memory, and executive
functions. Indeed, the development of these specic modules
will be the next step of the «Cognitus & Moi» program. Second,
the involvement of other components of social behavior (social
skills training and management of emotions) plays a key role in
the adaptative skills. In that regard, cognitive behavioral therapy
should be a useful treatment in addition to the «Cognitus &
Moi» program. ird, to our knowledge, the long-term eects
of cognitive remediation in intellectual deciency have not been
investigated in previous studies.
CONCLUSION
is article opens the path for new thoughts about the develop-
ment of specic cognitive remediation program in intellectual
disability. A new modular conception of cognitive remediation
in intellectual deciency should include neurocognition, social
cognition and metacognition training programs. Cognitive
remediation tools, based on visuospatial and attentional func-
tions, constitute promising tools to improve social cognition in
patients with intellectual disability and behavioral disorder. e
aim of this work is to enable these people to have access to cogni-
tive remediation treatments that are specically adapted to their
abilities and needs.
Intellectual disability is a public health issue and it is essential
to consider all the possible solutions to help improve these peo-
ple’s everyday life. Cognitive remediation is thus one of the most
promising tools that can be used. However, it must be used with a
very strict methodology in order to respect the persons limits and
preserved skills. Last but not least, cognitive remediation must be
included in a global care of the person and cannot be substituted
to other psychological treatments. is treatment depends on the
participation of dierent actors (e.g., family, therapist, educator,
etc.). e interaction between the dierent medical and social
actors will help establish a complementarity among the dierent
treatments carried out (medical treatment, psychomotor, speech
therapy). To conclude, the «Cognitus & Moi» program, by
using transfer strategies to daily life, is close to the real world. is
allows the child to practice skills in specic personal contexts,
which is a major challenge to improve mental resources.
AUTHOR CONTRIBUTIONS
CD, EP, CR, AM, and GC-S were implicated in the concept and
the design of «Cognitus & Moi». CD, CR, and EP wrote the paper.
GC-S and NF were involved in the review of the literature. All
authors read and approved the nal manuscript.
ACKNOWLEDGMENTS
e authors would like to thank the AFRC (nancial support),
Sylvia Silberman-Tessier (English editing assistance), Franck
Tarpin, Roland Hildebrandt and Lionel Paolini (technical
assistance-SBT Company), and le Conseil Scientique du
Vinatier.
FUNDING
«Cognitus & Moi» was nancially supported by AFRC
(Association Francophone de Remédiation Cognitive, FRANCE)
and SBT Company.
SUPPLEMENTARY MATERIAL
e Supplementary Material for this article can be found online at
http://journal.frontiersin.org//article/10.3389/fpsyt.2016.00010
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Conict of Interest Statement: e authors declare that the research was con-
ducted in the absence of any commercial or nancial relationships that could be
construed as a potential conict of interest.
Copyright © 2016 Demily, Rigard, Peyroux, Chesnoy-Servanin, Morel and Franck.
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Attribution License (CC BY). e use, distribution or reproduction in other forums is
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Supplementary resources (4)

... Our group recently developed the «COGNITUS & MOI» program, a cognitive remediation tool designed to train the attentional and visuospatial skills of [5][6][7][8][9][10][11][12][13] year-old children. COGNITUS is a friendly cartoon character that accompanies the child throughout various activities in paper-and-pencil, computerized, and at-home formats [25]. The «COGNITUS & MOI» program could be of particular interest concerning challenging behaviors in children with ID for several reasons. ...
... The «COGNITUS & MOI» program is a cognitive remediation tool, specifically for children, and is dedicated to attentional and visuospatial functions. A precise description of the program has been previously published [25]. Briefly, it is based on the following four main principles: ...
Article
Full-text available
Background: Comorbid psychiatric disorders are frequent in children with intellectual disability (ID). Given the limitations of drugs treatments, cognitive remediation could be a promising tool to reduce these challenging behaviors but evidence is still scarce. Our group recently developed the «COGNITUS & MOI» program that is designed to train the attentional and visuospatial skills in children with ID. This study investigates the efficiency of the «COGNITUS & MOI» program in this condition. Methods: Children (age: 6.00-13.11) with mild to moderate ID and behavioral problems, will benefit from a therapy during a 16 week randomized controlled trial. One group will be randomly treated with the «COGNITUS & MOI» program and the other with a motor skill and video viewing intervention. All participants will undergo a behavioral, functional and neurocognitive assessment at baseline, post-intervention, and 6-month follow-up. Primary outcome will be the change from the baseline of the score on the "hyperactivity - noncompliance" subscale of the Aberrant Behavior Checklist. Discussion: If the results are conclusive, the «COGNITUS & MOI» program could be added to the therapeutic arsenal against challenging behavior in children with ID. Trial registration: ClinicalTrials NCT02797418 . Date registered: 8th of June 2016.
... Initially used for brain-damaged patients, CR use was extended to schizophrenia (13), and later to several pediatric mental health conditions. CR effectiveness was demonstrated in children and adolescents with attention deficit hyperactivity disorder (ADHD) (14), anorexia nervosa (15,16), specific learning disorder (17), intellectual disability (18) and in early onset psychosis (19). ...
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Autism spectrum disorder (ASD) is associated with neurocognitive impairment, including executive dysfunctioning and social cognition (SC) deficits. Cognitive remediation (CR) is a behavioral training-based intervention aiming to improve cognitive processes. Its first use in psychiatry interested patients with schizophrenia, in whom promising results have been shown. Integrated CR programs targeting both social and non-social cognition have demonstrated to be effective in improving both cognitive domains and functional outcomes. CR studies in children and adolescents with ASD are still new, those regarding CR approaches combining social and executive functioning remediation are scares. One study examining the efficacy of cognitive enhancement therapy (CET) for improving cognitive abilities in ADS adults, showed significant differential increases in neurocognitive function and large social-cognitive improvements. Therefore, taking into account the overlap between ASD and schizophrenia, and considering the close link between executive functions (EF) and SC, we suggest that integrative approach in ASD could result in better outcomes. The present perspective aimed to highlight cognitive remediation (CR) programs contributions in ASD (especially in children and adolescents), and to discuss the value of combining social and non-social programs.
... 41 42 We choose the training tool, Happyneuron Pro (Happyneuron Pro is a product developed by Scientific Brain Training), because it is a well-known cognitive remediation product frequently used by the SLTs in France, and in particular by the SLTs participating in our study. Research and clinical studies have shown the effectiveness of the training programmes proposed in Happyneuron Pro software to improve cognitive functioning in patients suffering from different diseases and in normal ageing [43][44][45][46][47][48] Each training session lasts approximately 45 min and consists of 10 exercises of varying lengths, but not exceeding 4 min (see table 2 for details). The training programme stops automatically after 45 min, even if the patient has not completed the 10 exercises planned for the session. ...
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Introduction Recent studies on cognitive training in patients with Alzheimer’s disease (AD) showed positive long-term effects on cognition and daily living, suggesting remote computer-based programmes to increase training sessions while reducing patient’s travelling. The aim of this study is to examine short-term and long-term benefits of computer-based cognitive training at home in patients with mild to moderate AD, as a complement to the training in speech and language therapists’ (SLT) offices. The secondary purpose is to study training frequency required to obtain noticeable effects. Methods and analyses This is a national multicentre study, conducted in SLT offices. The patients follow training in one of three conditions: once a week in SLT office only (regular condition) and once a week in SLT office plus one or three times per week at home. The trainings’ content in SLT office and at home is identical. For all three groups near and far transfer will be compared with evaluate training frequency’s effect. Our primary outcome is executive and working memory scores in experimental tasks, and the secondary is neuropsychological tests and questionnaires’ scores. Linear models’ analyses are considered for all measures with a random intercept for patients and another for per practice. The fixed effects will be: three modality groups and time, repeated measures, (T0—pretraining, T1—post-training, T2—long-term follow-up) and the interaction pairs. Ethics and dissemination The study got ethics approval of the national ethical committee CPP Sud Méditerranée III (No 2019-A00458-49) and of the National Commission for Information Technology and Liberties (No 919217). Informed consent is obtained from each participant. Results will be disseminated in oral communications or posters in international conferences and published in scientific journals. Trial registration number NCT04010175 .
... Cognitus & Moi [18,19] Neurocognition : fonctions exécutives, mémoire et fonctions visuospatiales 1 essai clinique randomisé en cours CRT [20,21] Neurocognition : flexibilité cognitive, mémoire et planification Plusieurs essais cliniques randomisés Gaïa [22] Cognition sociale : émotions faciales 1 essai clinique randomisé IPT [23] Neurocognition et cognition sociale : attention, mémoire verbale, flexibilité cognitive, formation des concepts, perception visuospatiale, émotions faciales, théorie de l'esprit, langage, expression émotionnelle et résolution de problèmes 1 méta-analyse MCT [24,25] Métacognition et cognition sociale : style attributionnel, saut aux conclusions, théorie de l'esprit Plusieurs essais cliniques randomisés RECOS [26,27] Neurocognition : mémoire de travail, mémoire verbale, attention sélective, fonctions exécutives, fonctions visuospatiales et vitesse de traitement 2 essais cliniques randomisés RC2S et RC2S+ [28][29][30] Cognition sociale : théorie de l'esprit, style attributionnel, perception et connaissances sociales Études de cas uniques 1 essai clinique randomisé en cours SCIT [31] Cognition sociale et métacognition : théorie de l'esprit, émotions faciales, saut aux conclusions et style attributionnel ...
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La réhabilitation psychosociale promeut le pouvoir de décision et d'action des personnes ayant des troubles psychiques et, partant, leur rétablissement. Pour ce faire, elle s'appuie sur des outils thé-rapeutiques et une posture soignante spécifiques. Une remédiation cognitive, une psychoéducation, un entraînement des compétences sociales et/ou une thérapie comportementale et cognitive peuvent être proposés en fonction des besoins et des objectifs de la personne, après une évaluation intégrative multi-disciplinaire ayant mis en évidence ses capacités, ses limitations et les éventuels obstacles à la réussite de son projet propre. Chaque action thérapeutique donne à la personne de nouvelles possibilités pouvant lui permettre de franchir ces obstacles. Les professionnels de santé mentale mettant en oeuvre la réhabi-litation psychosociale doivent être engagés et formés, gage respectivement d'une relation thérapeutique positive et d'une nécessaire technicité. Ils soutiennent la construction du plan de rétablissement de la per-sonne en coconstruisant avec elle son projet personnalisé de réhabilitation psychosociale. Ils établissent des liens entre le contenu des séances thérapeutiques et le quotidien de la personne, afin de favoriser la généralisation et le transfert des bénéfices. © 2020 Elsevier Masson SAS. Tous droits réservés.
... Various studies have been carried out on the effectiveness of the cognitive intervention on some components of executive functions [8,27]; but, there is no study on the effectiveness of family-based intervention for improving executive functions and social skills of this population. Since executive functions and social skills are not perfect in this population, children with ID have no appropriate performance under the social situations, and because executive functions predict social skills, families of these children are worried about their social skills; so, they help to reduce their worries, educational delivery, treatment, and rehabilitation of new strategies and to improve their personal/social independence. ...
... One promising alternative is cognitive remediation, which is designed to address underlying neuropsychological skills deficits (e.g., training in attention, memory, executive functioning) to mitigate the resulting psycholegal deficits. Previous researchers have advocated for investigation of this treatment with individuals with ID. 62,63 Unfortunately, investigations often systematically exclude individuals with deficits in intelligence due to concerns regarding generalizability, 64,65 and cognitive rehabilitation investigations have been generally neglected in defendants with ID. Thus, little is known about the relative effectiveness with this population. ...
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The Americans with Disabilities Act has allowed for greater participation of individuals with disabilities across a variety of contexts, most notably in employment settings. Individuals with intellectual disability (ID) are still precluded, however, from full participation in other contexts, and they are often relegated to the forensic arena without sufficient support, including after being adjudicated incompetent to stand trial (IST). Frequently, individuals who are adjudicated IST due to ID are committed to inpatient psychiatric hospitals that are unable to meet their unique needs. We argue that the provision requiring reasonable accommodations to secure meaningful participation in state-funded restoration efforts, explicitly covered by Title II of ADA, is both relevant and imperative for this group. Further, we argue that simple modifications to the forensic assessment process, as well as the trial itself, can provide the scaffolding to facilitate individuals' full and complete participation in the process, reducing the likelihood of an inappropriate determination as IST. In our opinion, failing to appropriately modify the forensic assessment, treatment, and trial process systematically excludes and uniquely disadvantages this population because individuals with ID are often able to meet the essential functions of participation except for interference from deficits commensurate with ID.
... If we think about the growing educational potential of videogames in formal and informal education, results of our study could be of some use to aiding in the design of computerized training programs for disadvantaged children (cf. Demily et al., 2016), in particular in identifying the most appropriate graphic visualization style for addressing specific visuospatial abilities. ...
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Use of videogames (VGs) is almost ubiquitous in preadolescents’ and adolescents’ everyday life. One of the most intriguing research topics about positive effects of VG use is about the domain of visuospatial competencies. Previous research show that training with videogames enables children and adolescents to improve their scores in visuospatial tests (such as mental rotation of shapes and cubes), and that such training could overcome gender differences in these domains. Our study aimed at (1) verifying the positive effects of videogame use in the visuospatial domain both for male and female adolescents and preadolescents and (2) verifying whether the visualization style (2D or isometric 3D) of the VG has an influence about the positive effects of gaming. Six measures of visuospatial competency were administered to 318 preadolescents (mean of age = 13.94 years, range 10–18) prior and after a 3-day training with 2D and 3D Tetris. Results indicate that (1) gaming on the whole has slight positive effects both for males and females in enhancing visuospatial competencies, at least in the short term, and (2) it seems that participants who used the videogame with 2D graphics obtained greater improvements in the mental rotation domain while the participants who used the videogame with 3D gobtained greater improvements in the spatial visualization domain. However, a general learning effect between T1 and T2 was measured, which was found regardless of Experimental condition, indicating that the effect of training with videogames can be less relevant than expected.
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La mémoire à court terme verbale (MCTV) agit en interaction avec d'autres fonctions cognitives (langage, raisonnement, lecture, etc.) Or, les personnes ayant une déficience intellectuelle (DI) présentent un trouble de ce système mnésique. L'objectif de cette étude est d'évaluer l'impact d'un entraînement de la MCTV sur le langage oral d'enfants présentant une DI. Nous avons proposé un programme de rééducation de la MCTV à sept enfants qui ont un tel diagnostic et une rééducation de la catégorisation à un groupe contrôle de six enfants ayant une DI. Une augmentation de l'empan à court terme a ainsi été démontrée, mais également une amélioration de certains aspects du langage. Un entraînement de la MCTV serait nécessaire chez ces enfants afin d'aider au développement de leur langage oral.
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It is estimated that 7.2 million people in the United States have mental retardation or associated impairments - a spectrum now referred to as "intellectual disability." This book provides professionals with the latest and most reliable information on these disabilities. It utilizes a developmental perspective and reviews the various types of intellectual disabilities, discusses approaches to classification, diagnosis, and appropriate interventions, and provides information on resources that may offer additional help. Case examples are included in each section to highlight specific diagnostic and treatment issues. The emphasis in this book is on the development of the person, the provision of interventions for behavioral and emotional problems associated with intellectual disability, and the positive support necessary for self-determination. It discusses the facilitation of transitions throughout the lifespan from infancy to maturity and old age. Additionally, the book reviews evaluations for behavioral and emotional problems, genetic factors, appropriate psychosocial, medical, and pharmacological interventions, and family and community support.
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“Working memory” is a term used to refer to the systems responsible for the temporary storage of information during the performance of cognitive tasks. The efficiency of working memory skills in children may place limitations on the learning and performance of educationally important skills such as reading, language comprehension and arithmetic. Originally published in 1992, this monograph considers the development of working memory skills in children with severe learning difficulties. These children have marked difficulties with a wide range of cognitive tasks. The studies reported show that they also experience profound difficulties in verbal working memory tasks. These memory problems are associated with a failure to rehearse information within an articulatory loop. Training the children to rehearse material is shown to help alleviate these problems. The implications of these studies for understanding normal memory development, and for models of the structure of working memory and its development are discussed. It is argued that the working memory deficits seen in people with severe learning difficulties may contribute to their difficulties on other cognitive tasks.
Chapter
The development and use of strategic skills may well be the most researched topic in the broad areas of learning and memory in the mentally retarded (see Detterman, 1979; Ellis, 1979). Interest in control processing in the retarded was spurred by the theoretical insights of Norman Ellis (1970). Having pioneered work on structural deficits in retarded learning (Ellis, 1963), he began to shift his research focus in the late 1960s to rehearsal processes as key factors in explaining the memory failures of retarded children. Ellis (1970) concluded that differential performance of mentally retarded and nonretarded individuals on memory tasks was due to the former’s failure to use active rehearsal strategies. For instance, retarded individuals recalled as many items as nonretarded individuals on the last few positions of a serial list, but significantly fewer items on the early positions of the list. It is important to note that the earlier items require active rehearsal processing for good recall. Since an increase in exposure time did not noticeably enhance memory for earlier items for retarded individuals, Ellis (1970) concluded that rehearsal deficiencies characterized the encoding processes of the mentally retarded.
Chapter
Much of our childhood is spent developing complex cognitive skills that as adults we may take for granted, including language, reading, mathematics, and reasoning. In the course of normal development, children show large increase in their WM capacity. This chapter provides a broad overview of the different approaches taken in rehabilitating cognitive functioning that either target WM function directly or have shown to improve WM function. These approaches include ones that focus on the ability to maintain specific kinds of information such as phonological or visuospatial information and those that focus on executive/attentional control skills. Children with intellectual disabilities, such as Down syndrome have benefited from training in rehearsal strategies. The chapter reviews the principles for successful training. The first general principle is the importance of variability in training. Two additional general principles for successful training are the length of training and the adaptability of difficulty. A final general observation is that there is a growing use of neuro-imaging techniques, such as functional magnetic resonance imaging to demonstrate and measure the effects of training interventions on neural activity. However, until there is a clearer understanding and set of expectancies for how compensatory processing is accomplished in the brain, these results should be interpreted with caution. Although review of the literature suggests the potential for remediation of WM, much more research is necessary to establish the extent to which WM can be improved and what types of remediation are most effective for different populations.
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The book is a collection of normative data for commonly administered neuropsychological instruments. Included are summary tables of normative data from numerous studies and meta-analytic tables for some tests, detailed critique of the normative studies for each instrument, brief information regarding the tests themselves (history, cognitive constructs, and different test versions), as well as statistical and methodological issues relevant to interpretation of neuropsychological test data. This book represents an updated and expanded edition of the original published in 1999.