STRATEGIES & INTERVENTIONS

Brain Injury and Executive Functioning

Rachel Toplis, PhDDr. Jonelle Neighbor

Executive Functioning The executive functions all serve a "command

and control" function; they can be viewed as the "conductor" of all cognitive skills.

Executive functions help you manage life tasks of all types. For example, executive functions let you organize a trip, a research project, a paper for school, and how to get dressed in the morning.

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Some things to consider Recovery sequence following a BI.

Higher Level Cognitive Processes such as executive functioning may be impacted for years or permanently.

Some skills impacted as a result of a BI may be fully or partially rehabilitated, other skills may need compensatory strategies.

Recovery to pre-traumatic achievement levels following head injury does not guarantee continued achievement at pre-injury rate. A head injury has major impact on new learning!

External to internal support.Individuals with executive dysfunction are

not always able to utilize the age appropriate internalized skills for well regulated problem solving. Therefore intervention often begins from an ‘external support’ position with active and direct modeling, coaching and guidance, which proceeds over time to an ‘internal’ process.

Executive Functions: Functional Definition

Self-awareness of strengths and limitations (what’s hard to do; what’s easy to do)

Goal settingPlanning/organizingInitiatingInhibitingSelf-monitoring and evaluatingStrategic thinkingFlexible shifting, adjusting, benefiting from

feedback (Feeney, 2005)

Examples of Functional Executive Skills Attention and Concentration New Learning Mental Processing Emotional Control Reasoning and Problem Solving Organizational Skills Memory Initiation

Executive Functioning DifficultiesSOCIAL: poor social judgment social disinhibition Egocentrism difficulty interpreting the

behavior of others

BEHAVIORAL: Perseveration impulsiveness poorly regulated attention disorganization (in thinking,

talking, and acting) dulled emotional

responses

PROBLEM SOLVING: decreased flexibility/

shifting slowed processing diminished divergent

thinking concrete thinking immature problem

solving weak self-monitoring inefficient responses to

feedback/ consequences reduced initiation weak goal formulation ineffective planning

What disabilities are impacted by dysexecutive functioning?

Traumatic Brain Injury

Specific Learning Disability

Attention Deficit / Hyperactivity Disorder

Autism Tourette’s Syndrome

Schizophrenia Depression Obsessive

Compulsive Disorder

Dementia Etc…..

Development of Executive Functioning

Attention and Self Control 6-12 mos

impulse control and self inhibition Early inhibition begins to be demonstrated

1-2 yrs About 1 year can inhibit a response and shift to a new response Some self monitoring and beginning ability to identify errors

3-6 yrs General increases in attention, self control, concentration and

inhibition Gradual lessening in impulsivity Occasional preservative behaviors By 6 yrs is able to resist distractions and increase length of

attention span 7-9 yrs

Able to screen out irrelevant stimuli from selected target for attention

Attention and Self Control continued 10 yrs

Better able to pay attention to a selected target and screen out unwanted information

Impulse control is nearing adult levels 11-12 yrs

Able to monitor and regulate actions Attention is fairly mature Limits perseveration similar to an adult Temporary increase in impulsive behaviors

Adolescence Perseveration is rare Working memory increases dramatically

○ As cited in Richard, G.J., Fahy, J.K., (2005). The source for Development of Executive Functions. East Moline, IL: Linguisystems

Cognitive Flexibility• Helps students

– interpret information in multiple ways– change approaches and – select a new strategy if the first one is not working.

• Students must use knowledge from a variety of perspectives used in– reading comprehension– perspective taking in written language– shifting topics of conversation– topics of study within the school day

Cognitive Flexibility and Purposeful Behavior 2-4 yrs

2 ½ yrs. knowledge of rules ○ unable to shift or alter behavior ○ rely on perseveration

3 yrs can shift behaviors to adapt to knowledge of rules but ○ only to one rule at a time

4 yrs begin to shift between two simple task sets ○ have difficulty when response sets increase in complexity

Greater task completion because of increased mental flexibility

5-6 difficulty shifting between multiple rules with verbal prompts 6 yr olds have sharp increase of mental flexibility Perseveration decreases Increasing ability to learn from mistakes and generate new

strategies for solving simple problems

Cognitive Flexibility& Purposeful Behavior

7-9 yrs struggle with shifting behavior sets that are contingent on multiple

demands 8 yrs increased

○ focused, sustained attention, ○ ability to shift attention

9 yrs more success shifting from rules or sets depending on multiple or changing demands

10-12 years Improvement in ability to shift between multiple tasks decline in perseveration. greater ability to learn from mistakes create alternative strategies for multidimensional problems

Adolescence Cognitive flexibility is fairly mature Perseveration is rare Flexibility or the ability to change between performance

demands and initiate deliberate behaviors is greatly improved

Strategies and Interventions for specific areas

Inhibit Shift Emotional Control Initiate Working Memory Planning Organization of materials Self Monitoring

Based on the work of Gerard A. Gioia, Peter K. Isquith, Steven C. Guy & Lauren Kenworthy.

Behavioral Definitions & Expression of Dysfunction Inhibit – The ability to

not act on impulse or appropriately. Stop one’s own activity at the proper time.

Shift – Freely moving from one situation, activity, or aspect of a problem to another as the situation demands.

Has trouble “putting the brakes” on her behavior. Acts without thinking.

Gets stuck on a topic or tends to perseverate.

Emotional Control – Modulating / controlling one’s own emotional response appropriate to the situation or stressor.

Initiate – Beginning a task or activity.

Is too easily upset, small events trigger big emotional response, explosive.

Has trouble getting started on homework or chores.

Working Memory – The process of holding information in mind for the purpose of completing a specific and related task.

Has trouble remembering things, even for a few minutes; when sent to get something, forgets what he is supposed to get.

Planning – Anticipating future events, setting goals, and developing appropriate steps ahead of time to carry out an associated task or action.

Starts assignments at the last minute, does not think ahead about possible problems.

Organization – Establishing or maintaining order in an activity or place; carrying out a task in a systematic manner.

Self Monitoring – Checking one’s own actions during, or shortly after finishing the task / activity to assure appropriate attainment of goal.

Scattered, disorganized approach to solving a problem, easily overwhelmed by large tasks or assignments.

Does not check for mistakes, unaware of her own behavior and its impact on others.

Inhibit External

StructureProvide explicit,

extensive and / or clear set of rules and expectations and review frequently.

Limit distractions.

Reduce homework requirements to student’s capabilities.

Consistent, structured environment.

Inhibit Student Based

Teach response delay techniques, such as counting before responding.

Stop and Think methods.

Frequent breaks.

Peer role models, cross age tutoring.

Limit time in unstructured settings

Shift External Structure

Develop a set of positive routines and a set of alternative routines to build in appearance of flexibility.

External prompting, e.g., use cue cards, visual schedules etc.

Generate multiple ways to solve a problem / dispute.

Discuss multiple word meanings in jokes and riddles.

Shift Student Based

Two minute warning.

Make change in activity another routine.

Set time limits.

Place changes in schedule on calendar and draw attention to them.

Compare current situations to previous ones (compare and contrast).

Emotional Control

External StructureManage antecedents.Model appropriate

behavior.

If student responds with emotional outburst to school work, consider returning to mastery level or adjust academic demands.

Emotional Control Student Based

Review inhibition options.

Provide opportunities to talk about upcoming events.

Teach concrete / simple metaphor to increase emotional monitoring such as thermometer for measuring anger.

Initiate External Structure

Increase structure in the environment.

Use routines or steps of a task as a prompt.

May need external cue to get started.

Initiate Student Based

Learn systematic / structured approach to idea generation.

Provide “to do” lists on paper / index cards.

“Cookbook” with steps for activities.

Increase student’s metacognitive awareness of difficulty initiating.

Working Memory External Structure

Pre-teach framework for new information and guide attention to important parts.

Rate of presentation may need to be altered.

Information broken down into smaller chunks.

Rehearse and review new information frequently.

New information should be concrete and memorable.

Printed list of daily activities, locations, and materials needed.

Working Memory Student Based

Practice, practice, practice.

Encourage verbal rehearsal/self-talk.

Write a checklist of steps.

Learn ‘active listening’ techniques.

Visual Imagery.Teach to chunk

information.Use rehearsal,

repetition and paraphrase.

Provide study outlines

Planning ExternalStructure

Provide examples of how students might plan differently to reach the same goal.

Overtly teach goal setting

“Cookbook” of steps.

Adult modeling.Scripts

Planning Student Based

Call students attention to structure of new information.

Preview the organizational framework of new material in bullets.

Provide outline of lesson.

Use of organizational system such as planner.

Strategic approaches for activities such as SQ3R for reading.

Scripts Encourage self talk and internalize

problem solving strategies. Similar concept to social stories (which can also be useful for students with BI).1. identify / label the issue2. State the reason3. Offer a strategy4. General reassurance.

Scripts Example of a problem solving script

○ Identify / label the issue “This seems to be a problem”

○ State the reason “It’s a problem because…….”

○ Offer a strategy “Maybe we can………; that should help”

○ General reassurance “Great, it worked; there’s always something that works isn’t there”.

Organization External Structure

Increase external structure of the environment.

Model organizational skills.

Extra materials at home.

Checklists of required materials.

Cornell notes or two column notes

Graphic organizers

Note-taking templates

Guided notes

Organization Student Based

May need help from adult to organize materials.

‘Organization time’ at the beginning and / or end of the day.

Folders and planners

Writing checklists.

Self Monitoring External

StructureProvide

opportunities for self-monitoring.

Subtle cues. Set goals for

accuracy rather than speed.

Build in editing and reviewing as integral part of activity.○ types of errors to

look for○ how to check for

these errors ○ exactly how to

correct the errors

Self Monitoring Examples of editing strategies:

COPS -Checking work for capitalization, organization, punctuation, and sentence structure.

SQ3R Survey, question, read recite review is a strategy for studying from a text book.

Goal-Plan-Do-Review

Goal-Plan-Do-Review GOAL: What’s the goal? What are you

trying to achieve? What do you want to have happen? What’s it going to look like when you’re done? OBSTACLE: What is standing or could

stand in the way of you achieving the goal? What is the problem?

 

Goal-Plan-Do-Review

PLAN: So what’s the plan? What do you need to do? Do you need help? Do you want to do it as a team? Do you think that plan will work?? PREDICTION: So how well do you think you

will do? How many can you get done? On a scale of 1 to 10, how well will you do?

Goal-Plan-Do-Review DO: [Perhaps solving problems along

the way or revising the plan]

REVIEW: So how’d it work out? What worked? Anything that didn’t work? Why or why not? What are you going to try next time?

Self Monitoring Student Based

Self evaluation /regulation.○ how long will this

take, how long did it take?

○ Was it easy / hard for me?

○ What do I need to prepare for this?

Encourage charting their performance over time.

“Self talk” to increase awareness and attention to task.

Mental Processing Provide extra response time. Shorten length of communication to

student, focus on essentials. Avoid asking too many questions (rapid

fire). Provide written as well as oral directions.

Mental Processing Try not to put pressure on the student to

“hurry up, the class is waiting”. Provide a good note taking buddy so the

student can concentrate on one thing at a time e.g., listening to the presentation.

Attention and FocusSelf monitoring tasks.Getting students attention.

○ Auditory signals (ring bell, clap pattern, verbal signal ‘freeze’).

Attention and FocusMaintaining attention / active participation.

○ Use partial outlined study guides / sheets.

○ Use partner shares.○ Response cards – pre-prepared

responses depending on lesson (e.g., parts of speech, final punctuation marks). Students hold up the card they feel best answers a question.

Attention and Focus Limit Noise Remove distractions Provide concrete

visual cues Limit amount of info

on a page.

Adjust assignments. Focus on most

salient aspect of lesson.

Maintain brisk pace. Repeat instructions

Attention and Focus Use short and

concise instructions. Reinforce on-task

behavior. Give frequent

breaks.

Break assignments up.

Set up personalized cuing system based in classroom system(s)

Great Resource

• www.cokidswithbraininjury.com

○ www.cokidswithbraininjury.com/information-matrix/

Resources BrainSTARS Brain Injury: Strategies for

Teams and Re-education for Students.Dise-Lewis, Lohr Calery & LewisHands on manual broken into three parts

○ Defining brain injury, how it affects children at different developmental stages.

○ Specific problems and strategies.○ Advocacy and community resources.

REAP concussion management plan (Reduce-Educate-Accommodate-Pace). www.cde.state.co.us

Cokidswithbraininjury.com Offers the newest information on brain injury and

best practices for working with a child with BI in school.

www.cokidswithbraininjury.com/information-matrix/ LearNet: www.bianys.org/learnet

Resources for providing interventions and accommodations for a child with a brain injury.

Resources for Presentation www.Ldonline.org Gioia, G.A., & Isquith, P.K., (2002). New

Perspectives on educating Children with ADHD: Contributions of the Executive Functions.

Ehlhardt, L., Sublette, P., & Ness, B., (2007). Executive Function Impairments: Assessment, Management & Intervention.

Ylvisaker, M. (2006). Guidelines for supporting students with self–regulatory weakness.

Executive Functions: Wonderful when they work! Presented by Pat Sublette, Ph.D. Oregon Traumatic Brain Injury Education Coordinator.