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DELHI PSYCHIATRY JOURNAL Vol. 13 No. 2

OCTOBER 2010

Original Article

Comparative Efficacy of Cognitive Retraining Techniques and Remedial Training in Children with Learning Disability Shahzadi Malhotra*, Gaurav Rajender**, M.S. Bhatia***, K. Kanwal****, T.B. Singh***** *CNBC Hospital & MAMC, Delhi; **Fortis Escorts Hospital, Jaipur ***GTB Hospital & UCMS, Delhi, ****SMS Medical College, Jaipur *****Institute of Human Behaviour and Allied Sciences, Delhi

Abstract Background : Computer-assisted cognitive retraining approaches that work on the principle of cerebral plasticity are by now established rehabilitation methods for various neuropsychiatric conditions including Learning Disability. Also, remedial education is considered to be an integral part of management of learning disability. Objectives: To compare the efficacy of cognitive retraining techniques and remedial education for enhancing academic performance of children with learning disability. Sample & Methods: Pre-Post experimental design study was carried out with forty children(between seven to ten years of age), with diagnosis of mixed disorder of scholastic skills (ICD-10). Subjects in Group1 (n=20) were given 36 hours of manualized CR package over 18weeks, consisting of activities for sustained attention, visuospatial skills, visual memory; and verbal learning and memory. Subjects in group 2 (n=20) were given 36-remedial education sessions. Pre and post intervention assessment; was done using NIMHANS Index for Specific Learning Disability, Grade Level Assessment Device(GLAD).SPSS version 12.0 was used for descriptive and analytical statistical analysis. Results: Highly significant improvement was noted in mathematics (p > 0.01) for Group 1. Also, there was significant improvement in Hindi language of Group 2 (p > 0.05). Conclusion: Both-manualized cognitive retraining and remedial education over thirty six hours can help to partially improve scholastic performance in children with learning disability. The findings have implications for combining both the approaches for future educational curricula aiming at improved academic performance stemming from an enhanced skill base rather than from just educational based interventions. Keywords: Cognitive retraining, Remedial Education, Learning disability. Introduction Cognitive retraining (CR) is defined as “therapeutic modalities based on principles of cerebral plasticity which improve a brain injured person’s higher cerebral functioning or help the patient to better understand the nature of those difficulties while teaching him/her methods of compensation”12 . CR is used primarily those who have suffered from a traumatic brain injury (a stroke, tumor, or a head injury). These methods typically involve massed practice and drill approaches, along with 334

other psychologically based intervention methods. The two key elements of any cognitive retraining programme are: repetition to make the skill automatic, and appropriate reinforcement. The neuro-cognitive domains which are considered for retraining include-arousal and orientation, attention and concentration, memory, visual and spatial perceptual abilities, language and verbal skills, executive functions (reasoning, planning, organization, problem solving), life skills and social skills. Each identified skill is retrained using sequentially

Delhi Psychiatry Journal 2010; 13:(2) © Delhi Psychiatric Society

OCTOBER 2010

DELHI PSYCHIATRY JOURNAL Vol. 13 No. 2

increasing graded practice of activities using the method of saturation cueing followed by generalization. It makes use of the person’s stronger capacities to bolster the weaker ones. The process continues with diminishing degrees of assistance. A number of cognitive retraining methods have been utilized, most of which use specially designed computer software, and are called computer assisted cognitive rehabilitation (CACR). Few studies utilizing manualized retraining programmes report no difference in outcome between computer assisted and manualized cognitive retraining programs which are more suited in Indian context7. Neuropsychological studies, structural and functional imaging as well as electrophysiological studies provide evidence for central nervous system dysfunction in learning disabilities3-5. The literature on cognitive retraining strongly purports that cognitive retraining is an effective therapeutic module for enhancing cognitive skills. Recent evidence has suggested the efficacy of CR techniques for enhancing cognitive skills and academic performance of children with learning disability. Also, remedial education that includes both training in reading and use of exercises to improve phonic awareness have been reported to have a significant positive effect on LD7. Thus, limited research along with clinical experience also suggests that remedial education is an important component in management of academic problems in learning disability. However, there are no reported studies that have studied the comparative efficacy of these two approaches in the management of academic problems of learning disability. This study is an attempt in this direction. Aims and Objectives To study and compare the efficacy of cognitive retraining techniques and remedial education for enhancing academic performance of children with learning disability. Material and Methods Sample A pre-post experimental design study was carried out with a sample of 40 children with diagnosis of Mixed Disorder of Scholastic Skills (ICD-10) were recruited. These children between ages 7 to 10 years were studying in English medium schools in Delhi in Grade 1st to 4th and were reported to be having difficulties in school perfor-

mance. The diagnosis was confirmed using psychometric assessments. All children in the sample had average level of intellectual functioning, were attending school regularly without any study breaks. Children having any physical disability, subnormal level of intellectual functioning, any sensory impairments, children from single parent families or those having any other developmental disorder other than learning disability/any other neurological/psychiatric/or any other major medical illness were excluded from the study. This sample of forty was randomly divided into two groupsCognitive retraining group (Group 1) and remedial education (Group 2) group. Tools These children were assessed using the following: • NIMHANS Index for Specific Learning Disability:8 comprises of Malin’s Intelligence Scale for Indian Children (MISIC), Digit Vigilance Test, Bender Gestalt Test, Test of Visuo-Motor Integration, Auditory Memory Test, Benton Visual Retention Test along with tests of Academic Performance that include reading, writing, arithmetic, spelling and comprehension. For the present study, the Tests for Academic Performance of this battery were replaced by GLAD. • Grade Level Assessment Device (GLAD) for Children with Learning Problems in Schools9 to assess scholastic performance. The GLAD assesses the level of academic performance in three basic subjects viz. Hindi, English and Mathematics, in primary school children while systematically making an observation of the processing pattern in the child. Procedure Children and parents were educated about the nature and procedure of the study. The children were enrolled for the study after obtaining parental consent. All the activities that were to be used in order of administration, including each program’s description, material requirements, set up, instructions to students, response inputs, were compiled. The first few sessions were devoted to baseline assessments of children. All the baseline assessments were done individually. After the pre intervention assessments, the participants of group1 began the retraining sessions, which were to be

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administered twice a week, over eighteen weeks. Of these 36 sessions, 20 were individual sessions while 16 were group sessions. Each session lasted for one hour. Participants in Group 2 received remedial education sessions of one hour each. After the completion of the 36-lesson program, all the tests were re-administered. Analysis The data thus collected following the above design and procedure was interpreted using mean and standard deviation and compared through t-test using SPSS version 12.0. Results The mean age of the sample was 8.7 years (SD 0.87). The majority of the sample comprised of boys and the mean number of educational years for the sample was 5.7 years (SD = 0.66). Tables 1 and 2 show the mean and SD for pre intervention, post intervention conditions along with t values. For Group 1, the obtained t-values were found to be highly significant for Mathematics (p