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Transcript of Aproximación neo-Luriana Diagnostico Rehabilitación
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Neuropsychology Review, Vol. 9, No. 2, 1999
A Neo Lurian Approach
to
Assessment
and
Remediation
J. P. Das
1 2
The first part of this
article presents
an operational battery of
tasks
for
measuring
the four cognitive
processes
of
Planning, Arousal-Attention,
and
Simultaneous
and
Successive processing (PASS)
not
only based on the
qualitative
data provided in
Luna's
syndrome analysis, but also taken from tasks
in
experimental cognitive
psychology
and
neuropsychology.
The
second part
of the article presents
a
remedial program
based on
PASS
for
enhancement
of reading.
Because this
part
provides
in some
detail the efficacy of the
remedial
procedure, it simultaneously validates the
PASS
constructs as well.
In
both
parts of the
article,
I have been unmistakably guided by
Luria's views:
Tests are
approaches
to investigating cognitive functions, and the purpose of testing is to guide rehabilitation.
INTRODUCTION
I had the good fortune o f visiting Luria in October
and November of 1975. Beyond any doubt, he is the best
known and the most
frequently
cited Russian psychologist
in
Western psychological literature. As I wrote in a short
biography (Das, 1994), Luria remained productive under
Stalin, did not slow down when removed for a few years
from the Neurosurgical Institute to the Institute of De-
fectology, retained his optimism, and worked extremely
hard until his death
following
a third heart attack. When
I met Luria less than 2 years before his death, I found
that neuropsychology was thriving under his leadership.
He
held clinics three times
a
week
at the
Neurosurgical
Institute and through case presentations discussed many
fine points of assessing intellectual and emotional prob-
lems
as
well
as
methods
for
rehabilitation (Das, 1976).
He
worked hard until the end of his
life,
without any intention
of retirement, because, as he told me, he did not think that
mature
scientists
should retire and be left to grow roses
Luria was born in Kazan, Russia, o n July 16 , 1902,
and he died in Moscow on August 14, 1977. His ideas
have been extremely helpful in understanding cognitive
deficits,
including dyslexia. While extending Luria's neu-
1
University of Alberta,
Edmonton, Canada.
2A11 correspondence
should
be
directed
to the author at Developmental
Disabilities
Centre, 6-123D Education North, University
of Alberta,
Edmonton, AB,
Canada
T5G 2E5. E-mail:
ropsychological
findings to the
area
of
intelligence (Das,
Naglieri, and
Kirby,
1994), I and my coworkers found
that his syndrome analysis is consistent with a psychome-
tric analysis of four major cognitive
processes
composing
Planning, Arousal-Attention, and Simultaneous and Suc-
cessive
processes (PASS) that were directly derived from
his
writings
on the
functional
organization
of the
brain.
Further, Luria's clinical research into neurological
disor-
ders and rehabilitation after brain
injury
(Luria, 1963) has
influenced the construction of a remedial program (PREP)
for
ameliorating cognitive deficits, especially those related
to dyslexia and poor reading. Both of these, that is, con-
ceptualizing
intelligence in terms o f a battery o f
tests
and
constructing a remedial program, are the subject matter of
this article.
THE
PASS THEORY
IN
BRIEF
We must remember that underlying each method of psycholog-
ical investigations (and
this
is also
true
of psychological tests)
are
theoretical assumptions
about the structure of
psychological
processes and their breakdown.
Each
has its own
theory,
its own
ideology.
Therefore, any failure to recognize the theory or their
ideology which lies behind these tests, will quickly lead to disen-
chantment, and sometimes also to great
errors.
(Zeigamik el al.,
1977, p. 91)
The four PASS processes are presented in the con-
text of PASS theory of intelligence. This theory
identifies
three operational units that are important to understanding
107
1040-7308/99/0600-0107$16.00/0
1999 Plenum
Publishing
Corporation
KEY
WORDS: Luria;
neuropsychology;
assessment; neo-Lurian; PASS; remediation.
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108
Das
mental
functioning:
Attention, Simultaneous and Succes-
sive
processing,
and
Planning (Das, Naglieri,
and Kirby,
1994). Based on the work of Luria (1966a, 1966b, 1973),
the PASS theory is grounded in neuropsychology. A neu-
ropsychological view of intelligence is
different from
the
existing psychometric tests
of
intelligence;
it
attempts
to
determine
how the
mind works
by
anchoring
its functions
on the brain and by detecting dysfunctions. It
does
not
seek
to place
people
on a scale of
merit
and
therefore
is not a
tool
for
social selection as IQ tests have been used in the past.
The maintenance of attention and regulation of cor-
tical tone,
the
processing
and
storing
of information, and
the management and direction of mental activity compose
the activities of the
functional units that work together
to
produce cognitive processing (Das, Naglieri,
and
Kirby,
1994; Luria, 1966b).
In the schematic diagram of the PASS model shown
in
Fig.
1, there are
three main divisions: input,
process-
ing,
and output. Input arrives through
sense
organs—eyes,
ears, nose, tongue, and skin—as well as through muscles,
Fig. 1. Schematic diagram of the
PASS
model of cognitive processes.
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Das
Fig. 2. Scheme for assessment of Planning, Attention, and Simultaneous and Successive processing
(PASS).
that
are
associated with dyslexia? Several studies suggest
that this is possible (Das, 1992). The arrangement of tests
for
the PASS
functions
is given in Fig. 2.
As
can be
seen
in
Fig.
2, at the
most general lev-
el, PASS tests measure the four processes: Arousal-Atten-
tion,
Simultaneous-Successive processing, and Planning.
Then,
for
each
process, the
tests
are
named.
For
instance,
Arousal-Attention is divided into two major parts: sus-
tained attention and selective attention. A task for sus-
tained
attention is Auditory Vigilance, in which a man's
voice
and a
woman's voice
are
recorded
on a
tape recorder
cassette and played back to the individual who is being
tested. The man's voice says the names of five animals
and
five
items
of furniture. The
woman's voice does
the
same,
but the
animal
and furniture
words occur
at
random
at the
rate
of one per
second.
The
individual's task
is to tap
the table or desk in front of the tester whenever an animal
word is
spoken
by the man and a
furniture word
is
spo-
ken by the woman. This is an excellent task not only for
sustained attention,
but
also
for
false detections.
We
have
observed that children with attention
deficit
are identified
more easily
by
their
false
detection scores than
by
their
correct detections (Das, Mishra, and Kirby, 1994).
In
selective attention, we have two kinds of tasks; one
involves
selection at the level of reception of the stimu-
lus,
and the other at the stage of expression. The first task
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PASS
111
consists of a Posner-type test (Posner and Boies, 1971),
which
has two p arts. The first consists of letter pairs (BB,
DD,...)
that
ar e
identical (physical match)
and
some dis-
tractor pairs (BN, TP, ...) ,
which
are not. An individu al
is to cross out those that "look the same," that is, those
pairs that
a re
physically identical.
In
Name M atch,
on the
other hand,
the
letters, such
as Bb, Dd, are to be
crossed
out—one of them is written in the upper case, whereas the
other is written in the lower case. This is a receptive atten-
tion
test; selective
attention to the letter
pairs
occurs at the
stage
of
presentation.
In
contrast, selection
at the
expres-
sion,
or response,
stage
is
tested
by the
familiar Stroop
Test (Stroop,
1935). The
last card
in
Stroop
is
used
by
the PASS tests as a measure of interference in selecting to
respond to the color of the ink, a
conflict
card on which
the four
color
words are written in ink color that
does
no t
go with the word.
The
simultaneous scale
may
consist
of
Figure M em-
ory, in which the individual is allowed to look at a geo-
metrical figure such as a diamond for 5 seconds and then
find the figure embedded in another geometrical figure.
The other
simultaneous
tests are Tokens,
Design Con-
struction,
an d
Matrices, which
are
w idely used
for
verbal
(Tokens) and nonverbal spatial
tests.
The successive tasks
include Successive Ordering,
in
which
the
subject
is
asked
to watch the examiner as he or she turns over little chips;
then,
the
subject
is
required
to
turn over
the
same chips
in the order that th e exam iner did. In Serial Word Recall,
nine words, all fami liar one-syllable words, are presented
repeatedly in list lengths o f three to nin e words; the sub-
ject's
task is to repeat the words in the order in which they
were presented. Sentence Rep etition
similarly
in volves re-
peating a
sentence
that is read to the individ ual ("The p ur-
ple blued the green yellow"). Speech Rate (Hulme et al.,
1984)
is an
interesting test
in
which three words
are
given
to the individual and the subject is required to repeat the
words aloud as fast as possible ("Say 'egg, bu s, leaf, egg,
bus,
leaf, egg, bus, leaf,' on and on, until I ask you to
stop").
The
examiner stops
the
subject after
10
repetitions
and records the time that the subject
took
for repetition.
Sentence Questioning
is an
extension
of Sentence
Repe-
tition. After
th e
subject listens
to the
sentence, instead
of
repeating
it, the
subject mu st answer
a
question from
the
sentence ("The pink blued the yellow. Wh o was blued ?").
The p lanning tasks are the familiar Visual Search (a
number target embedded among
a field of
random ly scat-
tered num bers, a letter target am ong letters, a picture target
among pictures)
and
Trails
at the low
level
of
planning.
At the
medium level
o f
planning,
the
tasks
are
Matching
Numbers
(finding
tw o
numbers
that are
identical
in a row
of six numbers: 5736, 8295,7168,5736,4273,9571) and
Verbal
Fluency ("Say
as
many words beginning with letter
d as you
can").
At the
high level
of
plann ing, Crack-the-
Code and
Planned Composition have been used. Crack-
the-Code
is
like
th e
Mastermind game.
In
Planned Com-
position, the subject is show n a vague pictu re and is asked
to write a story about it on one page (see Das, Naglieri,
and Kirby, 1994,
for a
description
of
these PASS tasks).
A
diagram, presenting
the
division
of the
PASS tasks
and
their links to perception, memory (mnestic), and concep-
tualization, is provided in Fig. 2.
All these tasks are measures of the
processes
that
were previously identified. However, there are two ways
of evaluating whether or not these tests do measure these
processes—one
is
construct validity,
and the
other
is
through correlations and factor analysis, both of which
are discussed in the next section. We prefer construct va-
lidity to factor analysis.
To
measure attention, simultaneou s and successive
processing,
and
planning,
the
instruments must
be
consis-
tent
with
both the
"process
of
interest"
and the theoreti-
cal foundation from which th e theory wa s derived (Das,
Naglieri,
and Kirby, 1994, p. 102). Tasks used to measure
the
components
of the
PASS model
are
varied
in
terms
of
format
and
content. Figure
2
provides
a
brief overview
of
selected tasks used to measure each
functional
unit of
the PASS model. Extensive research demonstrating the
validity of these tasks has been conducted not only by the
author in his
lab,
bu t
also
by
outsiders (Naglieri, 1989;
Naglieri
et
al., 1989; Naglieri and Reardon, 1993). Many
of the above tests are now normed and included in the
Das-Naglieri
C ognitive Assessment System (1997).
SYNDROM E ANALYSIS AND MULTIVARIATE
ANALYSIS
Of fundamental concern here is the question of the
possible relationships between Luria's theory and data
drawn from
clinical investigations
of
subjects with brain
damage, and the various investigations as conducted by
a
variety of
researchers
using primarily multivariate sta-
tistical methods on data from normal and high-incidence
atypical populations (Das et
al.,
1975, 1979).
Das and
Jarman (1991) discussed this issue and suggested that the
relationship between these lines of research may be ex-
amined
from
three points
of
view:
1. To what extent should these investigations accept
Luria's model uncritica lly
a nd
merely apply
it in the
interpretation
of the
multivariate data?
2. To what extent does a logical and empirical relation -
ship exist between
the
results
of
Luria's investiga-
tions,
especially syndrom e analysis,
and the
results
from multivariate studies?
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112
Das
3. To
what extent
can or
should Luria's model
be re-
vised
and
affected
by the
outcome
of
various multi-
variate investigations?
With
respect
to the first question, we can find an in-
creasing acceptance
of his
work among neuropsycholo-
gists
and the correspond ing grow ing trend toward a .sys-
tems perspective in neuropsychology (Walsh, 1985,1987).
Briefly,
the second question relates to syndrome anal-
ysis. Its basis may be
found
in Luria's clinical technique
and the interlocking concepts of a
functional
system and
a behavioral syndrom e. Luria's te chni que of clinical re-
search was based on two principles:
1.
That
a
qualitative analysis
of
behavior
w as
neces-
sary,
utilizing
virtually
hundreds
of
tasks
in
some
cases, to lead to the
identification
of a defect.
2. That a single lesion or defect may demonstrate itself
in
diverse behaviors (Cicerone
and
Tupper, 1986).
The concept of a syndrome, as an extension of these
principles, was central to Luria's work, whereby a syn-
drome
was
identified
as a
constellation
of
signs
and
symp-
toms,
which, in turn, supplied what we would now term
an operational
definition for a
functional
system. Thus,
Luria's c linical method entailed the accumulation of con-
verging evidence
from
many tasks to
define
a syndrome.
The syndrome, then,
emerged
as a common cognitive pro-
cess that was disrupted in seemingly disparate tasks. This
clinical method,
in
turn, allowed Luria
to define
various
areas of
regional specialization
in the
brain
and to map
sets of functional systems that operate at various levels of
generality within and between these areas.
The research
process
that Luria utilized, therefore,
involved
the
definition
of a
variety
of
syndromes
by
iden-
tifying one or more cognitive processes that are common
to
tasks performed
b y
subjects
with
brain damage.
A
par-
allel approach is to operationally define co nstructs. This is
achieved
by identifying one or
more cognitive processes
that form
the
principal basis
for
individual differences
within
a set of tasks.
Such differences among normal
and
various atypical subjects
are
then supported
by
using mul-
tivariate methods, particularly factor analysis, whenever
possible.
The
approach adopted
in the
m ultivariate studies
by
Das
and
collaborators (Das
et
al., 1979; Das, Naglieri,
and Kirby, 1994) has been to focus mainly on the use of
tasks that were employed extensively by Luria or tasks
that
are very similar to them (although, as noted previ-
ously, the
tasks used
by
Luria
are
many
and frequently too
easy
for a nonclinical population), combined with other
tasks derived
from
the constructs of planning,
arousal-
attention,
and so forth.
Thus,
in
factor analytic terms,
this research is confirmatory in two ways: the selection
of
tasks and the hypothesized outcomes of the analyses.
By
using both a variety of
tasks
common to
Luria's
inves-
tigations and a wide selection
from
cognitive psychology,
and
then
by
varying subject populations with known dis-
orders, research support for the neo-Lurian model, PASS,
has gradually
emerged.
There
is increasing evidence that
multivariate investigations
of
normal subjects that parallel
syndrome analysis
can
inform theory
in
neuropsychology
(Clark, 1981; Dean,
1985).
Among
the multivariate techniques, a new advance-
ment, structural factor analysis, or LISREL, has added
significant
power
to
traditional factor analysis (McArdle,
1996).
This procedure allows hypothesis testing and,
through path diagrams,
can
even suggest causal pathw ays
between
cognitive
processes
and performance. "Is the ob-
served syndrome consistent with the model of cognitive
dysfunction?"
is the sort of question Luria would have
asked and answered had he been given the technique fo r
structural
factor analysis. However,
he
would
no t
have
looked for a model after doing the factor analysis, but
before; nor would he have determined tha t a certain
test
is
good
for
diagnosis
of the
syndrome merely because
it
has a high loading on a factor—for these are
some
of the
pitfalls in
using
the
advanced structural factor analysis,
as they were in traditional factor analysis. If multivariate
analysis must inform neuropsychological theory, w e can-
not,
for
example, assume
that a test of
planning
or
attention
is a
test
of that process simply because it loads on the same
factor as two other
tests
o f planning or attention. Clinical
data obtained
from
known
cases
of attentional or plan ning
deficit
must support the use of the test. Alternatively, the
test must have been used
in
cognitive psychology experi-
ments
as a
test
of
attention
or
planning.
The
last question
is
answered
in the
context
of the
section on Future Directions.
USING PASS THEORY FOR READING
REMEDIATION
When
primary school children
of
otherwise normal
intelligence fail to acquire reading, they are labeled as
learning
disabled, poor readers, or dyslexic. In an attempt
to remediate their problem in word reading, which
also
created
difficulties
in reading comprehension, we used a
cognitive
remedial program, PREP (The PASS Remedial
Program) (Das,
1999).
Remediation Program: PREP
The
PREP
w as
designed
to
improve
selected
aspects
of
children's inform ation-processing skills and to increase
their
word-reading
and
decoding abilities.
Procedures
such
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PASS
113
as rehearsal, categorization, monitoring of performance,
prediction, revision of prediction, word sounding, and
sound blending are an integral part of each of the PREP
tasks. Rather tha n being exp licitly taught by the tutor, chil-
dren receiving training in PREP are encouraged to become
aware of the use of u nderlying cognitive
processes.
This
is achieved throug h discussion
of
what they
did
during
the
tasks.
In this w ay, inductive inference and internalization
occur spontaneously rather than through deductive rule
learning
(Campione and Brown, 1987; Vygotsky, 1962).
The first part of the remediation program consists of
training tasks tha t challenge the children to use successive
or simultaneous processing when required. The objective
is
to
improve children's
"global"
processes.
These
pre-
cede
the
"bridging" tasks that have reading-related
ma-
terial. Children are taken through the training tasks in a
way that provides structured experience in using the tar-
geted cognitive process and facilitates the discovery and
internalization
of the strategies.
Transfer occurs as a result of the
fact
tha t the surface
structures of the tasks are diverse and not too much time
is spent in practicing a single task. "High road" transfer
(Salomon
and
Perkins, 1989),
a
transfer
of
principle,
oc-
curs in the "bridging" part of this program, as evidenced in
the study by Das
et al.
(1995) an d the new studies reported
in the next section. The "global" part is essential for the
program to be effective in imp roving word-decoding per-
formance, as shown in empirical studies (Das et al., 1995;
Das, Naglieri, and Kirby, 1994, chapters 9 and 10).
The PREP remediation program comprises 8 tasks,
each with a global-processing training
form
and a curric-
ulum-related bridging form. The global
form
has no read-
ing
content,
but it
provides
a
structured
series of exercises
that require the application of successive and simultane-
ous
strategies
as well as planning and attentional resource
allocation.
The
bridging form
has the
same cognitive
de-
mands as its matched global form, but it employs letters
and their combinations.
Each task has three levels of difficulty; the
easiest
level allows
the
child
to
have initial success with
the ma-
terials and to become familiar
with
the task and the expec-
tations
of the
training program.
The
more difficult levels
build on the
easiest
level through added complexity. De-
pending on the progress the child makes, the remediation
program typically requires 15 to 18 hours during approx-
imately
12
weeks.
In
each session,
one
teacher gives
the
PREP to four students.
Through its cognitive-processing tasks, the PREP
program provides children with an opportunity to develop
strategies for the key cogn itive processes required for word
decoding. In contrast to direct practicing of phonemic
skills,
the
cognitive strategies that children with reading
disabilities discover and learn by themselves in one part
of the program are then transferred to word decoding and
spelling
in the second part. The PR EP's application for im-
proving reading skills
in
und erachieving children
is
briefly
discussed
in the
next section.
The R emediation
Studies
The most recent study of the PREP program, using a
multistudent format, four students to one tutor, was done
by Carlson and Das
(1997),
to improve reading in under-
achieving ch ildren (the so-called Chapter 1 children) in
Hemet, C alifornia. In this study, one teacher instructed
children in two 50-minute sessions per week during a
3-month period. Both the PREP N = 22) and control
N = 15) group samples continued to participate in the
regular Chapter 1 programs offered in their schools. To ex-
amine
th e
efficacy
of the
PREP
in
terms
of
improvement
in
reading achievement, we administered Word Attack
and Letter-Word Identification subtests
of the
Woodcock
Reading Mastery Test—Revised (WRMT-R; Woodcock,
1987) at the beginning and the end of the study in a
pre/post design. The results showed that the children who
received PREP remediation gained substantially (almost
1 year in word reading an d decoding). Th e children in
the
control group
did not
show
any
improvement. How-
ever, when comparing the treated and untreated students
to determine the efficacy of PREP training , one must re-
member that the gains achieved for the group exposed to
PREP were compared with the gains of untreated students
in
the control group who were nonetheless receiving the
usual remedial education in their
classroom.
Although the data from the initial Hemet study pro-
vided support for the
utility
of the PREP program in im-
proving word reading, the number of children in the sam-
ple was small N = 22 in the remedial group, N = 15 in
the comparison group).
In
the second study in Hemet, we asked (a) if the
improvement due to the PREP could be replicated with a
larger group of Chapter 1 children, and (b) if the PREP
could also bring about any improvement in some of the
PASS cognitive
functions
underlying word reading and
decoding.
As mentioned earlier,
in
recent research
on
reading
disability, deficits
in
phon ological coding
and
articulation
have been identified as core difficulties
associated
with
reading disabilities, d espite norm al intelligence (Torgesen
et al.,
1987). We
have conducted studies that show that
successive processing is required for phonological coding
and
articula tion of sequences of letters and soun ds (Das,
Mishra, and Kirby, 1994; Kirby and Das,
1990),
and that
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PASS 115
the functional organization of higher cortical processes;
the
PASS model and the PREP provide a neo-Lurian ex-
pansion.
In conclusion, we hope that the PREP program is
just the beginning of a scientific approach to learning dys-
functions; it should be
developed
to
remediate math prob-
lem solving, and even beyond learning disabilities to other
learning problems such as attention deficit disorder.
The gap between a theory of cognitive functions and
amelioration of cognitive deficits needs to be bridged; our
approach is one attempt to
fulfill
this need. We have tried to
provide a
scientific basis
for
remediation
and
intervention
and, at the same time, question the rationale of adminis-
tering standardized intelligence tests.
Great changes have occurred in the field of intel-
ligence and the neuropsychology of cognitive processes
since Luria's time.
It
would
be a
mistake
to
ignore these,
and Luria would have been the first to advise us against
adhering to his original notions. The
greatest
changes
have occurred in our understanding of the functions of
the frontal lobes, and Luria longingly suggested that only
the young scientists who would follow him would be able
to discover such functions, which are planning and con-
sciousness.
The
challenge
for a
neo-Lurian theory
is to in-
vestigate the highest cognitive functions of humans, which
was
begun
by
Luria
and has
been followed
by
Sperry, Shal-
lice, and others (see Das et al., 1996), and the challenge
can be met not so
much
by
theorizing,
but by
observation
and more observation, to quote Pavlov's dictum.
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