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Schizophrenia Bulletin, Vol. 27, No. 2, 2001 S.M. Silverstein et al.
with less skill acquisition in treatments such as the Another recent approach utilizes computers to
University of California at Los Angeles Social and administer tasks based on neuropsychological tests or
Independent Living Skills modules (Mueser et al. 1991; exercises developed for remediation of cognitive deficits
Kern et al. 1992; Wallace et al. 1992; Bowen et al. 1994; in learning disabilities. Data from studies of neuropsy-
Corrigan et al. 1994; Silverstein et al. 19986; Silverstein chologically oriented computer exercises indicate that
et al. 1998e). One conclusion that can be drawn from improvement in neurocognitive functioning occurs, as
these studies is that patients who are impaired in their assessed via laboratory procedures (e.g., Burda et al.
ability to sustain attention or to remember material pre- 1994). As with the approach discussed above, there is lit-
sented to them will benefit little from the treatment. tle evidence that the improvements generalize to other
Neurocognitive deficits, including poor attention span, areas of functioning or that they enhance response to
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Shaping Attention Span Schizophrenia Bulletin, Vol. 27, No. 2, 2001
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Schizophrenia Bulletin, Vol. 27, No. 2, 2001 S.M. Silverstein et al.
textual stimulus features while suppressing responses to tional impairments when they were placed in IPT (Pierce
irrelevant stimuli; and (2) divided attention, defined as the et al. 1997). All of this stresses the importance of devel-
ability to simultaneously monitor two or more sources of oping effective interventions for schizophrenia patients
information that are relevant for behavioral responses. who need to improve their basic attentional abilities as a
Sturm et al. studied the effectiveness of a cognitive reme- precursor to being introduced to other treatments.
diation intervention comprising distinct intervention com-
ponents targeted separately at alertness, vigilance, selec-
tive attention, and divided attention in populations of The Use of Behavioral Techniques to
patients with focal brain damage of vascular etiology. Enhance Neurocognitive Functioning
One of their key conclusions was that "specific attention
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Shaping Attention Span Schizophrenia Bulletin, Vol. 27, No. 2, 2001
criterion for reinforcement is advanced to the next step attention of sufficient duration to enable learning in other
(e.g., 5 minutes of continuous attention). This sequence treatment modalities) is clearly not part of the current
of reinforcing, changing criteria for reinforcement, fad- repertoire, and the criterion is unlikely to be reached by
ing reinforcers for previous "versions" of the behavior, watching others. Similarly, simply making reinforcers
and limiting reinforcers to behavior meeting the new cri- contingent upon meeting the target behavior is unlikely to
terion, is then repeated until the behavior resembles the be effective, because the target behavior occurs at an
final desired response. A strength of shaping is therefore extremely low frequency. That is, if the strategy that is
that it allows for specific learning techniques to be used used is to reinforce patients every time they, for example,
to develop and strengthen behavior that does not nor- pay attention for 20 minutes, this strategy is unlikely to
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Schizophrenia Bulletin, Vol. 27, No. 2, 2001 S.M. Silverstein et al.
patient to a high of over 250 sessions (nearly 2 years) for Bellus et al. (1999) compared the academic skill per-
another. Similar individual differences were found for formance of seven lower functioning patients in shaping
these seven patients in overall psychiatric status, as classes to a group of seven higher functioning patients in
improved continuous work performance scores did not traditional academic classes over a 9-month period. Most,
appear to be systematically related to scores on the but not all, patients in the Bellus et al. study had chronic
Nurses' Observation Scale for Inpatient Evaluation, 30 psychotic disorders. In shaping classes, feedback was
items (Honigfeld, Gillis, and Klett 1966). given at varying temporal intervals across patients, con-
Menditto et al. (1991) used shaping procedures to sistent with their individualized goals, while in academic
increase the attention span of seven forensic inpatients classes, feedback was given at fixed 10-minute intervals.
with severe and persistent schizophrenia or schizoaffec- Additionally, in shaping classes, shaping chips were
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Shaping Attention Span Schizophrenia Bulletin, Vol. 27, No. 2, 2001
schedule was implemented wherein he was given 5 cents A second limitation of past studies is that they were
and a piece of candy each time he opened his eyes. This not controlled. In essence, all past reports, with the
eventually led to increases from 10 percent to over 80 per- exception of Bellus et al. (1999), were a series of case
cent of the time in keeping his eyes open, with subsequent studies. This raises the possibility that nonspecific factors
greater spontaneity and participation, and responses that may be responsible for all or part of the gains made by
were more relevant to the group. patients receiving shaping interventions. Controlled stud-
ies that vary critical intervention components (e.g.,
amount, nature, and frequency of reinforcement) are nec-
Interpretation of Effects essary to rule out this possibility. Such studies will also
lead to greater efficiency and effectiveness of shaping
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Schizophrenia Bulletin, Vol. 27, No. 2, 2001 S.M. Silverstein et al.
who benefit most from the treatment. Regarding the first 1994; Stratta et al. 1994; Vollema et al. 1995; Bellack et al.
issue, patients have typically been chosen based on clini- 1996; Wexler et al. 1997) and to treat executive function-
cal judgment For example, patients have been chosen for ing impairments widiin the context of a larger neurocogni-
shaping on the basis of being the most "regressed" tive rehabilitation program (Wykes et al. 1999). The suc-
patients in a treatment program (Menditto et al. 1991) or cess of errorless learning strategies in the cognitive
being "low functioning" and having made little or no rehabilitation of schizophrenia raises the issue of whether
gains in prior efforts at more traditional skills training systematically pairing reinforcement with errorless learn-
approaches (Silverstein et al. 199&/)- It is possible that ing procedures might lead to increased gains in neurocog-
efficiency of treatment would be improved if there were nitive rehabilitation. Similar pairings can be tried with
methods to identify relevant candidates and place them in computer-assisted forms of neurocognitive training. A
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Shaping Attention Span Schizophrenia Bulletin, Vol. 27, No. 2, 2001
deficits in schizophrenia. Schizophrenia Bulletin, Kern, R.S.; Green, M.F.; and Satz, P. Neuropsychological
18(l):21-26, 1992. predictors of skills training for chronic psychiatric
Brenner, H.; Roder, V.; Hodel, B.; Kienzle, N.; Reed, D.; patients. Psychiatry Research, 43:223-230, 1992.
and Liberman, R. Integrated Psychological Therapy for Kern, R.S.; Green, M.F.; and Goldstein, M.J.
Schizophrenic Patients. Toronto, Canada: Hogrefe and Modification of performance on the span of apprehension,
Huber, 1994. a putative vulnerability marker to schizophrenia. Journal
Burda, P.; Starkey, T.; Dominguez, F.; and Vera, V. of Abnormal Psychology, 104:385-389, 1995.
Computer-assisted cognitive rehabilitation of chronic psy- Massel, H.K.; Corrigan, P.W.; Liberman, R.P.; and Milan,
chiatric inpatients. Computers in Human Behavior, M.A. Conversation skills training of thought-disordered
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Schizophrenia Bulletin, Vol. 27, No. 2, 2001 S.M. Silverstein et al.
Psychotic Patients." Presented at the New York State Spaulding, W.D.; Fleming, S.K.; Reed, D.; Sullivan, M.;
Office of Mental Health Research Conference, Albany, Storzbach, D.; and Lam, M. Cognitive functioning in
NY, December 1997. schizophrenia: Implications for psychiatric rehabilitation.
Posner, M.I., and Boies, S.W. Components of attention. Schizophrenia Bulletin, 25(2):275-289, 1999a.
Psychological Review, 78:391-408, 1971. Spaulding, W.D.; Reed, D.; Sullivan, M.; Richardson, C ;
Posner, M.I., and Rafal, R.D. Cognitive theories of atten- and Weiler, M. Effects of cognitive treatment in psychi-
tion and the rehabilitation of attentional deficits. In: atric rehabilitation. Schizophrenia Bulletin,
Meier, M.J.; Benton, A.L.; and Diller, L., eds. 25(4):657-676, 1999ft.
Neuropsychological Rehabilitation. Edinburgh, Scotland: Spaulding, W.D.; Storms, L.; Goodrich, V.; and Sullivan,
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Shaping Attention Span Schizophrenia Bulletin, Vol. 27, No. 2, 2001
Nebraska Symposium on Motivation, 1983: Theories of phrenia. Journal of Humanistic Psychology, 6:68-74,
Schizophrenia and Psychosis. Lincoln, NE: University 1966.
of Nebraska Press, 1983. pp. 283-318.
Wallace, C.J.; Liberman, R.P.; MacKain, S.J.; The Authors
Blackwell, G.; and Eckman, T.A. Effectiveness and
replicability of modules for teaching social and instru- Steven M. Silverstein, Ph.D., is Associate Professor of
mental skills to the severely mentally ill. American Psychology in Psychiatry, Weill College of Medicine of
Journal of Psychiatry, 149:654-658, 1992. Cornell University, New York, NY, and Director, Second
Wexler, B.; Hawkins, K.; Rounsaville, B.; Anderson, Chance Program and the Schizophrenia Neurocognitiion
M.; Semyak, M.; and Green, M. Normal neurocognitive Laboratory at New York Presbyterian Hospital, White
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