Principles of Cognitive Rehabilitation

By Vahid Nejati

Principles of Cognitive Rehabilitation is designed to familiarize readers with the deep-rooted principles of cognitive rehabilitation and cognitive training. Presenting a new comprehensive framework in cognitive rehabilitation for therapeutic, educational, and research purposes, this volume introduces five components that are introduced for cognitive rehabilitation, including primary principles, patient, practitioner, program, and process (5Ps). Detailing the developmental stages of a program will help readers understand the logistics of cognitive interventions and also help them to design and evaluate their own therapeutic interventions.

• Introduces a fundamental basis for cognitive rehabilitation trainings
• Outlines a new comprehensive framework in cognitive rehabilitation for therapeutic, educational, and research purposes
• Conceptualizes the concepts of cognitive rehabilitation
• Discusses experimental results and evidence related to cognitive rehabilitation
• Features the codification of principles into five core components to organize a process of remediation
• Describes future perspectives in the field

• Language: English
• Publisher: Academic Press
• Release date: Nov 25, 2022
• ISBN: 9780443187513

Vahid Nejati

Dr. Nejati is a professor of Cognitive Neuroscience at Shahid Beheshti University. He serves as the president of the Iranian Association of Cognitive Science and Technology (since January 2019). He has designed and developed several cognitive rehabilitation packages and cognitive assessment tools in the field. Being a visiting scholar at both the University of Regensburg in Germany and Uppsala University in Sweden, he has published several journal papers and books in the fields of cognitive rehabilitation.

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Front Cover for Principles of Cognitive Rehabilitation - 1st edition - by Vahid Nejati

Principles of Cognitive Rehabilitation

Vahid Nejati

Shahid Beheshti University, Tehran, Iran

Table of Contents

Cover image

Title page

Copyright

Dedication

Preface

Chapter one. Foundation of Cognitive Rehabilitation

Abstract

1.1 Introduction

1.2 Perception

1.3 Attention

1.4 Memory

1.5 Higher cognitive functions

Chapter two. Primary principles of cognitive rehabilitation

Abstract

2.1 Introduction

2.2 Principle of neural plasticity

2.3 The principle of compensation

2.4 Principle of relearning

2.5 The principle of verbalization

2.6 Principle of automatization

2.7 Principle of errorless learning

2.8 Principle of multisensory learning

2.9 Principle of active learning

2.10 Principle of observational learning

2.11 Principle of implicit learning

2.12 Principle of emotional learning

2.13 Principle of offline learning

2.14 Principle of directed forgetting

2.15 Principle of processing level

2.16 Principle of context-dependent learning

Chapter three. Program-related principles of cognitive rehabilitation

Abstract

3.1 Introduction

3.2 Principle of model

3.3 Principle of specificity

3.4 Principle of overload

3.5 Principle of variety

3.6 Principle of repetition

Chapter four. Process-related principles of cognitive rehabilitation

Abstract

4.1 Introduction

4.2 Principle of assessment

4.3 Principle of goal setting

4.4 Principle of support

4.5 Principle of transferability

4.6 Principle of termination

Chapter five. Patient-related principles of cognitive rehabilitation

Abstract

5.1 Introduction

5.2 Principle of motivation

5.3 Principle of effort

5.4 Principle of expectation

5.5 Principle of diversity

5.6 Principle of family empowerment

Chapter six. Practitioner-related principles of cognitive rehabilitation

Abstract

6.1 Introduction

6.2 Principle of adherence

6.3 Principle of treatment competency

6.4 Principle of ethics

6.5 Principle of alliance

6.6 Principle of teamwork

References

Further reading

Index

Copyright

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Notices

Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary.

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Dedication

To Farzaneh and Nikki, my wife and daughter.

They have been lovingly patient and supportive during my work on this book.

Preface

Fostering cognitive capabilities in both health and clinical setting is a crucial matter in rehabilitation, behavioral, and cognitive sciences. The plasticity of the brain throughout a life span raises hope that brain functions may be modulated so that subsequent behavior would be altered and improved. Cognitive rehabilitation aims to improve cognitive functioning with the ultimate goal of behavior modification and enhancement.

In cognitive rehabilitation studies, notwithstanding publication biases, successful and beneficial findings are as common as unsuccessful findings (Taatgen, 2016). This may be a result of the quality of cognitive rehabilitation interventions. In other words, if we consider the chain of genes-brain structure-brain (cognitive) function-behavior, any positive changes in cognitive functioning should be spurred into behavior and genes. The variety of programs that have been designed without considering the main principles of cognitive functioning leads to this perturbation. A simple search in Appstore or Google Play using brain and memory training as keywords delivers about 1000 applications for the user. Although the majority of these programs are developed by software developers without any considerable knowledge of cognitive science, they are directly prescribed for cognitive rehabilitation and training. The merging of entertainment and recreation with therapeutic tools poses a threat for therapists. The business under the games on the one hand and the attractive and charming face of the games on the other hand give this industry its power. It is worth mentioning that cognitive rehabilitation is not restricted to the rehabilitation program. Currently, various and available programs influence the other main components of cognitive rehabilitation including the therapist, patient, process, and primary principles. It is our duty, as critical as life and death, to clarify the borders of cognitive rehabilitation with recreational activity. I find the first step in this line to be setting a clear definition of the principles of cognitive rehabilitation. Due to the earlier mentioned concerns, it is necessary, now more than ever, to define the principles of cognitive rehabilitation. Therapists must have the insight and knowledge to rate and evaluate training applications and programs based on the principles of cognitive rehabilitation.

The codification of principles is a cornerstone for establishment and development in any scientific field. Concerning my experience in teaching cognitive rehabilitation, I have found that for therapists, techniques are more interesting than principles. Therapeutic techniques are leaves that must be stemmed from the principles at the root. Otherwise, they are short-lived and ephemeral. In the same way, therapists without a rich knowledge of principles are downgraded to technicians.

This book addresses therapists, researchers, and students at all academic levels in the disciplines of rehabilitation sciences, behavioral sciences, and neuroscience, familiarizing them with the deep-rooted principles of cognitive rehabilitation and cognitive training. Some of these principles have been borrowed from specific therapeutic methods and others, more specific to cognitive rehabilitation, originate from cognitive and brain sciences and may apply to other therapeutic techniques.

Chapter one

Foundation of Cognitive Rehabilitation

Abstract

In this chapter, the concepts and domains of cognitive rehabilitation are defined. Cognitive rehabilitation is the process of remediation or compensation of cognitive deficits and related outcomes through a well-established program(s) by the therapist. Cognitive rehabilitation breaks down behavioral problems into cognitive impairments and tries to recover the behavioral problems through the improvement of impaired cognitive underpinnings. Five main components of cognitive rehabilitation are primary principles, program, process, patient, and practitioner, namely the 5Ps. The domains of cognitive rehabilitation are as broad as domains of information processing. Therefore, this chapter explains information processing at four levels: perception, attention, memory, and higher cognitive functions. Then, construction, evaluation, dysfunction, and rehabilitation of each level are described.

Keywords

Cognitive rehabilitation; perception; attention; memory; higher cognitive functions

1.1 Introduction

All psychological, neurological, and psychiatric disorders influence behavior, and they are all diagnosed, evaluated, and rated by the presence and intensity of behavioral symptoms. All behavioral problems are rooted in the brain and may be modified at the brain level, resulting in recovery and/or improvement. The majority of interventions target the brain indirectly through behavioral tasks. The variety of behaviors on the one hand and the variety of brain structures and networks, on the other hand, make a point-to-point mapping from behavior to the brain very difficult and imprecise. Hence, cognitive functions can serve as the medium to ease the situation, because, for one, the neural correlates of cognitive functions are almost clear, and two, normal and abnormal behaviors can be broken down into cognitive underpinnings. Cognitive functions in a narrow channel between a two-sided funnel enable us to modulate brain injuries and behavioral problems through goal-directed and cognitive-based behavioral tasks (Fig. 1.1).

Figure 1.1 Two-sided funnel of brain and behavior. Therapeutic methods at the levels of behavior, cognitive function, and brain run the loop of brain behavior cognitive function, with certain domains, at the middle level, target for cognitive rehabilitation.

Therapeutic intervention can be applied in both levels of the brain and behavior (the broad side of each funnel). Brain stimulations target the brain areas directly and, in classic rehabilitation and psychotherapy, the behaviors are targeted for modification. It is worth mentioning that there is a mutual interaction between the brain and behavior. Both behavioral and brain interventions on each side of a two-sided funnel influence one another, see plasticity principle in Chapter 2.

The outstanding question here is why cognitive rehabilitation is necessary, despite the two influential and mutually interdependent categories of interventions? The answer lies in the importance of cognitive rehabilitation, which will be further discussed in this book. But, for now, let’s just say that behavioral intervention improves behavioral problems through other overlapping behaviors and their cognitive underpinnings. Thus, the main influential cognitive deficit remains relatively untouched (see the principle of compensation, part 1). In contrast, targeting cognitive functions can influence all subordinate behaviors. In the same way, each behavior is controlled by a distributed brain network. Hence, the neural correlates of each behavior are not located in any one specific brain area that could be stimulated.

Definition

The interdisciplinary nature of cognitive rehabilitation depicts a cloudy space void of rigid boundaries. A proper definition for cognitive rehabilitation can give it the necessary domains and territories. Sohlberg and Mateer (1989) as two pioneers in the field of cognitive rehabilitation define cognitive rehabilitation as the therapeutic process of increasing or improving an individual’s capacity to process and use incoming information so as to allow increased functioning in everyday life (Sohlberg & Mateer, 1989). Ben-Yishay and Prigatano (1990) define the term as the amelioration of deficits in problem-solving abilities in order to improve functional competence in every- day situations (p. 395) (Ben-Yishay & Prigatano, 1990). Such definitions do not, however, consider the domains and components of cognitive rehabilitation. So, when referring to cognitive rehabilitation, I will be using the following functional definition throughout this book. Cognitive rehabilitation is the process of remediation or compensation of cognitive deficits and related outcomes through the well-established program(s) by the therapist. The main components of cognitive rehabilitation as highlighted in this definition should be clarified in detail. The first component is the process. The process is rooted in the dynamic notion of cognitive in rehabilitation. Indeed, cognitive rehabilitation is not a passive dictation of a prescription by a practitioner, without any modification during the treatment period. The second point in the definition approaches. Remediation and compensation are two approaches to cognitive is the rehabilitation. The remediation approach with a task-based program tries to empower the impaired cognitive function, while the compensatory approach with an education-based program tries to teach beneficial strategies to the patient to interact with the environment with exist cognitive functioning. The next point in the definition is the target of cognitive rehabilitation which is cognitive deficits and outcomes. The ultimate goal of cognitive rehabilitation is to reduce the mental, social, and academic outcomes of cognitive deficits, rather than merely improve certain cognitive functions. This refers to the concept of transferability, which will be discussed extensively in chapter four. The next point addressed in the definition of cognitive rehabilitation is a program. A well-established program refers to a program that is developed based on the theoretical model, with respect to the primary principles. Cognitive rehabilitation without a program is like driving without a mental or physical map. And the last but not least point referred to in the definition is a therapist. As is the case with all other therapeutic methods, cognitive rehabilitation requires a therapist. I mean supervision by the therapist, not his or her mere presence. Thus, home exercises prescribed by a therapist fall under the umbrella of cognitive rehabilitation. Based on this definition we have five main components for cognitive rehabilitation, namely the 5Ps for primary principles, patient, practitioner, program, and process. Fig. 1.2 illustrates the 5Ps as the main components of cognitive rehabilitation.

Figure 1.2 The main components of cognitive rehabilitation. Primary Principles, Patient, Program, Practitioner, and Process (5P) are five main components of cognitive rehabilitation The P-shaped book on the floor, patient’s chair, table, practitioner’s chair, and the big P around all components refer to Primary Principles, Patient, Program, Practitioner, and Process, in order.

Domains

From an outline perspective, our brain is a processor between incoming sensory information and outgoing motor responses. The flow of information starts from the receptor and ends in the executive organ, from sensation to motion. The sensation, in the initial stage, originates from the receptor, sensory organ, and terminates in the primary sensory area, and the motion in the late stage, starts from the primary motor area and ends in the motor organ, muscle. Sensation and motion are afferent and efferent components of the cognitive processor. There are several cognitive functions in between including perception, attention, memory, and higher cognitive functions. All of these cognitive components are trainable through cognitive rehabilitation. Although sensation and motions are trainable, training of these functions is out of cognitive rehabilitation scope. It must be noted that sensation and motion, as initial and late loops of the behavior chain, are not independent of cognitive functioning, and could benefit from cognitive rehabilitation. Several studies described that impaired sensory (Elyashiv et al., 2014; Nejati, 2018a) and motor (Foroughan et al., 2018; Sandroff et al., 2015) functioning influences cognitive functions. Beyond correlational studies, sensory and physical training improves cognitive functioning (Karawani et al., 2018; Nejati & Derakhshan, 2021). However, rehabilitation of basic sensory functions, such as visual and auditory acuity, and musculoskeletal functioning, joint range of motion, is partially independent of cognitive functioning.

In sum, although sensory information and motor activities are used for cognitive training, sensory and motor rehabilitation per se are excluded from the realm of cognitive training.

After sensation, the flow of information continued to motion. There are several patterns for the interaction of cognitive functions in the flow of information processing including: serial, parallel, and cascade (Fig. 1.3) Serial pattern assumed that each stage of information processing occurs at a time in a serial processing. A parallel pattern states that more than one process typically occurs at the same time, in processing. And cascade processing considers an overlap for different processing stages in task performance. Independent of the pattern, in the following section, each cognitive domain is explained and the common cognitive training approaches and programs are discussed and listed.

Figure 1.3 Different models about the flow of information processing: serial (A), parallel (B), and cascade (C). One processing per time, simultaneous processing at the same time, and overlap of processing in order.

It is worth mentioning that the flow of information processing is not unidirectional from sensation to motion. In a bottom-up information processing approach, cognition shapes form perception and sensation whereas, in a top-down approach, cognitive functions and our expectation shape our perception of to-be-selected information.

1.2 Perception

Construction

Although sensation and perception are used together, this dichotomy is a false one (Gibson, 1979; Montague, 2019). Sensation and perception are two distinct constructs in the course of information processing. Sensation refers to the basic process of capturing and converting external information, various type of physical energy, into neural signals, called sensory transduction, and its transition to the brain whereas perception refers to interpreting what that signal means (Schwartz & Krantz, 2017). In neural terms, sensation starts from the sensory organ and ends at the primary sensory area of the brain whereas perception is attributed to the higher sensory/associative areas. Contrary to unimodal sensation, perception is multimodal and subserves secondary and/or tertiary sensory areas and multimodal associative areas to integrate different sensory modalities to form a unique perception. On the other side, the border between perception and attention is not so clear (Nejati, 2021b). Some earlier accounts differentiate perception from cognition based on content and format. Accrdingly, perception encompasses nonconceptual content in the iconic format, but cognition has conceptual content in discursive format (Bermúdez, 2009; Williams, 2019). However, Cermeño-Aínsa (2021) stated that both perception and cognition can use conceptual and nonconceptual contents and be vehiculated in iconic and discursive formats.

With respect to the integral concept of perception, merging different sensory modalities with an organized arrangement shapes the perceptual function, called spatial abilities. Spatial abilities are the ability to synthesize, analyze, and organization of sensory information (Sack et al., 2008) and inner mental images (Sack et al., 2005). The spatial abilities include a variety of ingredients: visualization, spatial relation, closure speed, the flexibility of closure, closure speed, spatial-temporal, and wayfinding (Soluki et al., 2021). Furthermore, some perceptual abilities are considered semi-spatial abilities such as mathematical abilities, including number sense (Yazdani et al., 2021). Spatial abilities enable individuals to handle three spaces: the space of navigation, the space around the body, and the space of the body. The space of navigation helps us to find our way in an environment, the space surrounding our body is related to the immediate replacement of the body or object around it, and the space of the body is the space of our perception from the inside and the outside representations (Tversky et al., 1999). The spatial abilities enable individuals to perform plenty of academic and daily activities such as mathematical abilities and achievement (Xie et al., 2020; Yazdani et al., 2021), reading (Gabrieli & Norton, 2012; Giovagnoli et al., 2016), motor skill (Voyer & Jansen, 2017), wayfinding performance (Jansen-Osmann et al., 2007; Munion et al., 2019), perspective-taking ability (Cardillo et al., 2020), and social cognition (Nejati, Moradkhani, et al., 2021). Beyond the correlational studies, the training of spatial abilities was used to improve the impaired above-mentioned abilities (Cheng & Mix, 2014; Hawes et al., 2015; Sorby et al., 2013; Uttal et al., 2013). At the neural level, several neuroimaging studies described the role of the posterior parietal cortex in spatial abilities (Gogos et al., 2010; Sack, 2009; Wolbers et al., 2006).

Dysfunction

The impairment of perceptual functions leads to an inability to analyze the environmental stimuli meaningfully. Higher order deficits of multimodal sensory processing are known as agnosia. Although agnosia has been described in all sensory modalities, visual agnosia has been more extensively studied (Bauer, 2006). It must be noted that the perception is multimodal and agnosia lies in the impaired integration. Perception consists of several levels of representation from low-level sensory images to more abstract representation. The representation of information in perceptual context is organized with serial and parallel pathways, with feed-forward and feedback mechanisms, across discreet but overlapped networks. Impairment in these networks and mechanisms leads to agnosia (Devinsky et al., 2008). For instance, prosopagnosia is an inability to recognize familiar human faces (Bornstein & Kidron, 1959; Kress & Daum, 2003), finger agnosia is an inability to detect the touched finger (Anema et al., 2011), simultagnosia refers to an inability to recognize an object based on several simultaneous features (Michel & Henaff, 2004), optic ataxia characterized by impaired voluntary reaching for a visually presented target with misdirection and dysmetria (Perenin & Vighetto, 1988; Rossetti et al., 2003), alexia is an effortful letter-by-letter reading strategy to arrive at a word’s identity (Friedman et al., 1993), and akinetopsia is an inability to see moving objects (Zeki, 1991). Indeed, agnosia does not result from impaired basic sensory functions or impaired higher cognitive functions but is related to the integration and manipulation of perceived information.

The impairment in perceptual functions have been described in several psychopathological conditions such as schizophrenia (Postmes et al., 2014; Silverstein & Keane, 2011), stroke (Rowe & UK, 2009), dementia (Uhlhaas et al., 2008), Parkinson's disease (Coundouris et al., 2019), specific language disorder (Lubert, 1981), developmental coordination disorder (Schoemaker et al., 2001) attention deficit hyperactivity disorder (Micoulaud-Franchi et al., 2015; Mihali et al., 2018), learning disabilities (Garje Mona et al., 2015), mathematical learning disabilities (Yazdani et al., 2021), dyslexia (Serniclaes et al., 2001), hearing impairment (Jerger, 2007), and cerebral palsy (Ego et al., 2015). These conditions could be considered potential candidates for cognitive rehabilitation for perceptual training.

Evaluation

Assessment of perceptual functions mainly relies on visual stimuli. Although spatial abilities are not limited to the visual modality, the visualization of test materials provides a situation to assess different dimensions of spatial abilities. Table 1.1 listed the selected tests of perceptual/spatial functions.

Table 1.1

Note. n.s, not specified.

Rehabilitation

With respect to the multimodal nature of perception, intact integration of information is crucial for perceptual functioning. Perceptual training could be classified based on the perceptual domains. Each perceptual domain integrates different sensory modalities to feed respective higher cognitive functions. In Table 1.2 some perceptual training programs were listed with respective domains and references

Table 1.2

1.3 Attention

Construction

Attention is located between perception on the one side and memory and higher cognitive functions on the other side. It lets the flow of information from perception to memory and higher cognitive functions and back. The externally-driven attention makes a bottom-up processing and direct perception and internally-driven attention shapes a top-down modulation of information and respective constructive perception (Katsuki & Constantinidis, 2014).

Attention alters the priority weights of information in perception and thus re-structures the input-output function of the perceptual systems (Kahan, 2012; Watzl, 2017; Wu, 2014). Attention is a fundamental cognitive function with a variety of domains based on the conceptual framework. This cloudy nature of attention makes it a part of all cognitive functions. On the one hand, attention selects relevant information and makes perceptions from incoming raw sensory information. On the other hand, attention is influenced by our prior memory, intention, and goal (Watzl, 2017; Wu, 2014). In sum, in the flow of information processing, attention selects relevant information from irrelevant one, keeps them alive, and shifts or divides the resources between different information (Nobre et al., 2014). The basic components of attention are related to incoming sensory information (filtering, focusing, automatic shifting), the presence of information in the processor (capacity, maintenance, effort, arousal), and outgoing motor information (response intention, initiation, and inhibition) (Cohen et al., 1993). The capacity of the attentional system has a limited processing capacity, thus attentional system must select the relevant information for processing. Furthermore, the speed of information processing is crucial for resource management. Different domains of attention subserve distinct brain areas (Posner & Rothbart, 2007). Attention networks include alerting, orienting, and executive attention (Posner & Petersen, 1990). Alerting, described as arousal, vigilance, and sustained attention, refers to maintaining a vigilant state and readiness to react. This network involves the right frontal lobe, the right parietal lobe, and the locus coeruleus, and is influenced by the norepinephrine system. Orienting indicates the selection of specific information from a variety of sensory inputs. The orienting network involves the superior and inferior parietal lobe, the frontal eye fields, the superior colliculus of the midbrain, and the pulvinar and reticular nuclei of the thalamus, with the function of the cholinergic system. The executive network is involved in conflict monitoring. The anterior cingulated cortex and the dorsolateral prefrontal cortex are involved in executive network, the network with a dopaminergic system, Table 1.3 (Callejas et al., 2004; Posner & Dehaene, 1994).

Table 1.3

Source: Adapted from Callejas et al. (2004) and Posner & Dehaene (1994).

Another theoretical model of attention is the hierarchical model. The hierarchical model of attention describes five levels of attention: focused attention, sustained attention, selective attention, alternating/shifting attention, and divided attention, from the bottom to the top (Sohlberg & Mateer, 2001). In detail, focused attention refers to the selection of relevant information. Sustained attention indicates effortful maintenance of attention on information for a long duration continuously. Selective attention is a selection of relevant information in the presence of irrelevant one. Shifting attention refers to switching between different sets of information, and divided attention refers to keeping attention on two or more ongoing processes simultaneously.

Evaluation

A theoretical model of attention is crucial to provide a framework for the assessment and training of attention. With respect to the attentional networks model, the attentional network test is a measure of alerting, orienting, and executive attention (MacLeod et al., 2010). Based on the hierarchical model, digit symbol, continuous performance, Stroop, Wisconsin card sorting, and oddball tests are used for the assessment of focused, sustained, selective, shifting, and divided attention, in order (Sohlberg & Mateer, 2001; Table 1.4).

Table 1.4

Dysfunction

Given distributed function and structure of attention, a variety of behavioral and cognitive impairments suffer from impairments of attention such as attention deficit hyperactivity disorder (Kim, Yum, et al., 2014), autism spectrum disorder (Chien et al., 2015), specific learning disabilities (Bednarek et al., 2004), traumatic brain injury (Stierwalt & Murray, 2002), epilepsy (Kavros et al., 2008), multiple sclerosis (Dujardin et al., 1998), Parkinson disease (Solís-Vivanco et al., 2011), dementia (Ballard et al., 2001), Alzheimer disease (Rizzo et al., 2000) schizophrenia (Salgado-Pineda et al., 2003), depression (Sommerfeldt et al., 2016), bipolar disorder (Camelo et al., 2013), anxiety (Najmi et al., 2012), obsessive-compulsive disorder (Muller & Roberts, 2005), etc.

Rehabilitation

Attention training could be classified into two groups based on their origin: western attentional process training and eastern attentional state training. The former targets the attention networks through process training and the latter stress the achievement of a state leading to more efficient self-regulation to balance body-mind interaction (Tang & Posner, 2009).

Based on the attentional training approach, attentional abilities, such as other cognitive functions, can be improved by activating them by a stimulation drill approach. Repeated stimulation and involvement of the attentional system, through conflict-related tasks, is assumed to promote the performance of attentional functioning (Sohlberg & Mateer, 2001). With respect to the different domains of attention with distinct functions, each domain should be targeted for training separately. Attention training programs consider a basic theoretical model and propose some progressive exercises for improvement.

Several metaanalysis studies found that attention is malleable (Peng & Miller, 2016; Rapport et al., 2013; Wass et al., 2012) This training effect is fast, even after 77 min of training (Wass et al., 2011), and transferable to the other cognitive functions and behaviors (Nejati, 2020, 2021c).

The successful transferability of attention training originates from the basic and fundamental position of attention in the flow of information processing. For instance, given the hierarchical model of attention, focused attention is the basis of all cognitive functions. Sustained attention as the ability to keep information alive are crucial for working memory. Selective attention, the ability to select relevant information in the presence of competitors, forms inhibition, especially interference control. Shifting attention supports cognitive flexibility as another component of core executive functions. Finally, divided attention is a crucial component of multitasking. In Table 1.5 some attention training programs were listed.

Table 1.5

1.4 Memory

Construction

Memory is the ability to encode, store, and retrieve information from the experience (Tulving & Craik, 2000). Based on the multimodal model of memory, encoding brings information to the short-term memory and after that holds it in short-term memory, and then it moves to long-term memory, through rehearsal (Atkinson & Shiffrin, 1968). In long-term memory, as the final destination of information in memory, information is available for retrieval but not kept in an active mode. The basis of information storage is different in these three types of memory. In sensory memory, information is stored based on encoding in a short period, about milliseconds, if a pattern can be extracted from encoded information, it moves to short-term memory. Attribution of meaning to this pattern or finding a meaningful connection between this pattern and stored information transfers information to long-term memory (Dehn, 2011).

Long-term memory can be classified into two main components based on the accessibility of memory for conscious awareness: explicit (conscious or declarative) memory and implicit (unconscious or non-declarative or procedural) memory (Tulving & Schacter, 1990). There are two types of explicit