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5/11/2016
1
Supporting the Executive Functions of Older Adolescents:
Fostering Self-Regulation
Mary R.T. Kennedy, Ph.D., CCC-SLP
Professor, Chapman Universitywww.neurocognitvelab.com
May 13, 2016 1
Supporting Executive Functions with Self-regulation
• Adolescents with TBI are at risk of executive dysfunction which impacts transition to college/community and success.
• Transition needs can be addressed by speech-language pathologists (SLPs) who ‘coach’ students to self-regulate their own learning, time management and self-advocacy.
• Assessing self-regulation is done using surveys & interviews.
• Functional treatment planning & intervention will be described using an evidence-based coaching approach that uses motivational interviewing and metacognitive strategy instruction.
May 13, 2016 2
Clinical Researcher
EducatorAdvocate Self-Regulation
Metacognition
Cognitive Rehabilitation
College after TBI
May 13, 2016 3
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Time ordered agenda
9:00• Executive functions & Self-regulation
9:30• Preparing for post-secondary education
10:00• Coaching: What is it?
10:45• Assessing Self-regulation & Goal collaboration
11:00
• Coaching self-management, -studying & learning, advocacy
May 13, 2016 4
TBI Non-Combat Stats
• >5 million living with disabilities from TBI in US
– 1.7 new injuries annually; most mild
• Leading cause of accidental death or disability worldwide– U.S. leading cause of
disability < 34 years old
– 57 million hospitalized http://www.cdc.gov/Features/dsTBI_BrainInjury/
May 13, 2016 5
Post-concussion syndrome (PCS)
Physical
• Fatigue
• Visual
• Headaches
• Balance, tinnitus
• Nausea
• ‘Foggy’ feeling
Cognitive
• Attention
• Word finding
• Slow processing (reading, listening)
• Memory
• Executive functions & self-regulation
Psychosocial
• Adjustment to lifestyle change
• Injury & symptom validation
• Irritability, short fuse
• Depression
• Anxiety, stress
• Frustration
• Feeling alone
May 13, 2016 6
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Post-concussion syndrome: A cluster
Physical
Cognitive
Psychosocial
May 13, 2016
http://www.cdc.gov/headsup/basics/concussion_recovery.html
7
Young Adulthood: A Critical Time
• Brain development
o Blooming & pruning
• Context: School & Community
o Peers, social
o Higher executive functions
o Game changes, less support
May 13, 2016 8
• Injured before collegeoLower graduation rates (National
Longitudinal Transition Study, Wagner et al., 2005)
o IEPs & transition teams are important to successful college entry (Glang et al., 2008)
oAbout half are linked to campus disability services (Tobis & Glang, 2008)
What happens when students with TBI go to college?
May 13, 2016 9
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High school & college students
o More strategies, more effort
o Decreased GPA, outside activities & relationships with peers
o Worse concentration, memory, problem-solving
What happens when students with TBI go to college?
May 13, 2016 10
Model of Cognitive Processing
Sense of Self
Anticipation Goal Selection Preplanning Monitoring
Drive
Attention Visual-Spatial Memory Alertness
Autonomic-Emotional Sensory/Perceptional Language
Motor Cognition
Sequencing
Executive Functions
May 13, 2016
Stuss & Benson, 1986
11
The Widening Gap of Executive Functions
Pre-K Elementary Secondary Post-secondary
Executive functions
May 13, 2016 12
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• integrative cognitive processes that determine goal-directed and purposeful behavior in daily life– formulate goals;
– initiate behavior;
– anticipate the consequences of actions;
– plan and organize behavior in logical sequences
– “to monitor and adapt behavior to fit a particular task or context.” (Cicerone et al., 2000, p. 1605).
Executive Functions are…
May 13, 2016 13
Executive Functions (Dawson & Guare, 2012)
1) Response inhibition
2) Working memory
3) Emotional control
4) Sustained attention
5) Task initiation
6) Planning/prioritizing
7) Organization
8) Time management
9) Goal-directed persistence
10) Flexibility
11) Metacognition
May 13, 2016 14
Examples of Cognitive ImpairmentsCognitive Process College students with disabilities may…
Attention: Focusing on a specified activity, behavior, or task. Levels from basic to complex include: focused, sustained, alternating, divided.
• Be distractible during class, while studying, or during conversation
• Talk out of turn• Have a low tolerance for frustration• Not follow through on assignments or personal
commitments
Memory: Gathering information so that it can be stored and then recalled at a later time.
• Have difficulty recalling facts, new information for tests• Forget what they read• Be unable to connect information; draw inferences when
reading• Not know when assignments are due • Rely on poor memory strategies when studying, such as
repetition
Receptive language: comprehending and decoding meaning – both explicit & implicit language.
• Be slow to respond to questions• Become frustrated by group interactions that require
listening and responding to multiple speakers• Have difficulty understanding implicit information when
reading texts• Focus on explicit information in texts while missing implicit
information
May 13, 2016Kennedy & O’Brien, 2016
15
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Examples of Executive Function Impairments
EF Process College students with disabilities may…
Attention control: Deciding what to pay attention to, what to ignore, how long to attend, & when to switch attention.
• Get too focused on one part of an assignment • Be easily distracted in class, during exams, & while studying• Become distracted when completing long assignments• Not recall or learn material
Memory Control (working memory): Holding information in one’s mind in order to manipulate it; retrieving details when needed; remembering to do something at a later time (i.e., prospective memory)
• Have trouble multi-tasking (e.g., listening & taking notes)• Make decisions based on limited information• Forget important details • Miss punch lines or story conclusions • Have difficulty weighing options
Cognitive self-regulation: Monitoring the need for strategies; selecting & implementing strategies.
• Underestimate the need to study & use strategies Underestimate the amount of time & effort studying takes
• Not adjust or change study strategies even when current ones are ineffective
• Know study strategies, but do not use them
Emotional self-regulation:Managing and bouncing back from everyday ups and downs without over-reacting.
• React in ways that are out of proportion to the situation • Get upset or overly discouraged when given feedback • Have fluctuating emotions or “mood swings” over a short
period of time• Get easily irritated if someone disagrees with them
May 13, 2016Kennedy & O’Brien, 2016
16
Impairments associated with TBILanguage & Cognition Executive
Functions
May 13, 2016 17
COGNITIVE & EXECUTIVE FUNCTION IMPAIRMENTS
DUAL DISABILITIES
May 13, 2016 18
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Transition Planning
• Taxonomy of Transition Programming (Kohler, 1996)
– Student-focused planning
– Student development
– Interagency collaboration
– Family involvement
– Program structures
www.nsttaac.org
May 13, 2016 19
What Do Students Need to Succeed after High School?
• SReg learning are the strongest predictors of learning at work and in college
1. Goal level
2. Persistence
3. Effort
4. Self-efficacy
May 13, 2016
Sitzman & Ely, 2011
20
Executive
FunctionsMetacognition
Awareness
Rehabilitation,
NeuropsychologyOther Fields of Psychology
Self-Regulation
May 13, 2016 21
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Self-regulation
Goal –
Self-monitor
Strategy decision – Self-control
Implement strategy
Compare (& adjust)
Metacognitive beliefs &
sense of self
May 13, 2016
Revised from Flavell, 1979; Kennedy & Coelho, 2005
22
Self-regulation is…• the ability to assess ones own (hence the
‘self’) cognitive and emotional states and to make decisions about what to do in light of that assessment. – a group of cognitive processes
– are the ‘meta’ manipulations that allow us to monitor and control our own emotions, thinking, and actions.
– goal- oriented behavior that is adjusted in a real world context.
Carver & Scheier, 1991; Kennedy & O’Brien, 2016; Sitzman & Ely, 2011
May 13, 2016 23
SELF-AWARENESS
WHAT ARE YOU GOOD AT DOING?
List 5 things
May 13, 2016 24
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Adolescents & Young Adults with Executive Dysfunction: Sense of Self?
Developmental
ADD/ADHD
ASD
Intellectual Disabilities
Acquired
TBI
Concussion
Stroke, other
May 13, 2016 25
Executive Functions
Sense of self
AcquiredDevelopmental
May 13, 2016
College
Work
College
College
Work
Work
Context is Key
26
Percentage by student group registered with Disability student services (DSS)
(NCES report, Raue & Lewis, 2011)May 13, 2016 27
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Percentages of colleges that document these groups of students
(NCES report, Raue & Lewis, 2011)May 13, 2016 28
Preparing Students with Executive Dysfunction for Post-secondary Education
• Transition teams before & after HS – Vocational rehabilitation
• Educate student & family– Role of Disability services &
cultural shift
– Emphasize independence
– Plan ahead: meet with DS, early course registration
• Translate executive functions
• Coach time-management, study & learning, self-advocacy
May 13, 2016 29
Context: Role of Disability Services
• Maintain medical/psychological documentation in a confidential manner
• Determine if condition is a disability• Identify and assist with implementation or
reasonable accommodations– Modify accommodations as needed IN ORDER TO PROVIDE
EQUAL ACCESS
• Provide information and referral• Promote independence, self-advocacy, self-
expression, finding your own way• Provide “support” to those who seek it
May 13, 2016 30
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Context: Role of Students
• Provide medical and/or psychological documentation to Disability Services
• Participate in the process of determining and implementing accommodations
• Inform Disability Services when accommodations are not working, need to be modified, or if symptoms change
May 13, 2016
Independence & Advocacy
31
Context: Role of Instructors
• Refer students to Disability Services
• Participate in the process to determine and implement accommodations
• Identify essential course components for accommodations to be determined
• Request assistance from Disability Services as needed
May 13, 2016 32
What is Dynamic Coaching?
• A form of intervention that supports and instructs individuals in the use of their own executive functions to be able to assess situations accurately that and solve problems that arise and to accomplish both their proximal (immediate) and distal (long range) goals.
‘dynamic’ reflects these self-regulation processes are on-going and ever changing with students’ needs, situations and contexts.
May 13, 2016 33
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Traditional Therapy
Coaching Approach
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Partnership
Context
Clinician as expert
34
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Coaching
Self-expertise
35
Partner with Students to
May 13, 2016
develop goalsplans (strategies, timelines)establish routines identify barriers
36
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Partner through Coaching
Coach
Motivates, Inspires
Models
SupportsInstructs
Guides
May 13, 2016 37
Evidence in support of Coaching College Students
• Ylvisaker & Feeney, 1998; Ylvisaker, 2006• Quinn, Ratey & Maitland, 2000• Parker & Boutelle, 2009• Dawson & Guare, 2012• Field, Parker, Sawilowsky & Rolands, 2010; 2011• Kennedy & Krause, 2011• Kennedy, Krause & O’Brien, 2014• O’Brien, Schellinger & Kennedy, (strategy outcomes) in
preparation• Kennedy, Schellinger & O’Brien, (qualitative outcomes) in
preparation
May 13, 2016 38
Coaching is based on best-practices
Supports change (& recovery) naturally through experiences
Strive for Effortless behavior
Self-awareness & metacognitive strategies
Person-centered goals
Instruct Self-Regulation
Maintenance & Generalization
May 13, 2016 39
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• Systematic Reviews
– Tate et al. (2014) – JHTR
– Kennedy et al. ( 2008) – Neuropsychological Rehabilitation www.ancds.practiceguidelines
– Cicerone et al. (2000, 2005, 2010)
– Institute of Medicine (IOM, 2011) report on cog rehabilitation
Scientific Evidence for Using Self-regulation through Metacognitive Strategies
May 13, 2016 40
Metacognitive strategy instruction/Direct Instruction had a larger tx effect on functional activities than ‘control’ tx for adults with sufficient attention & memory.
Practice Standard
Intervention for executive functions after traumatic brain injury: A systematic review, meta-analysis and clinical recommendations (Kennedy et al., 2008)
May 13, 2016 41
• Combining the DI with SI to achieve the best outcome!! Kennedy et al., 2008
Promoting Metacognitive Strategy Instruction
Impairment outcomes Activity/Participation
Non-MSIinstructions
MSI instructionsEffect sizes
May 13, 2016 42
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“Treating” Self-awareness
• Educational material
• Experiential, activity based intervention
• Learning (about self) while doing
– Using tools, strategies
– Feedback (self, others)
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Tate et al., 2014
43
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Table2.1.Similaritiesanddifferencesbetweendynamiccoachinganddidacticinstruction.Coachescanberehabilitationprofessionals,instructors,orpsychologists.
DynamicCoaching DidacticInstruction
Coachprovidesindividualizededucation Coachprovidesindividualizededucation
Bothcoach&studentareexperts Coachistheexpert
Emphasizesprocess&result Emphasizesprocess&result
Coachasksquestions,studentsselectstrategies
Coachidentifies&selectsstrategies
Coachreliesinterviews,questionnaires&behaviortogatherinformationaboutstudent
Coachreliesontestscores&behaviortogatherinformationaboutstudent
Coachmodelsself-regulationandprovidesstructure,studentprovidescontent
Coachmodels,providesstructure,andprovidescontent
Goalsareidentifiedbystudentwithcoachingguidance
Goalsareoftenindependentoftheinstruction
Coachingoccursinthecontext,inrealtime,e.g.,collegecampus
Instructionoccursoutofcontext,e.g.,therapyroom
Isteambasedinwhichstudentselectsteammembers
One-on-onetherapyorinstructionaretypical
Lessintensive,e.g.,onesessionperweek Moreintense,e.g.,2-3timesperweek
Process-basedgoalsareasimportantastheproduct-basedgoals
Productbasedgoalsareimportant
Distributedpracticeoccursnaturally Practiceisartificial,outofthecontextfromwhichstrategieswillbeused
Feedbackcomesnaturally,frommultiplesources
Feedbackcomesfromthecoach
Self-regulationisemphasized,i.e.,-monitoring,implementing,adjusting
Learningthestrategyisemphasized
44
Coaching involves…
Guiding students using active listening, questioning = motivational interviewing (Miller & Rollnick, 2013)
"a collaborative, goal-oriented style of communication with particular attention to the language of change. It is designed to strengthen personal motivation for and commitment to a specific goal by eliciting and exploring the person's own reasons for change within an atmosphere of acceptance and compassion."
Collaboration
Evocation
Autonomy
May 13, 2016
MacFarland, L. (2012). Canadian Journal of Speech-Language Pathology and Audiology, 36/1.
45
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What do Coaches do?
• Instruct in strategies, with emphasis on strategy use in context
• Work to extinguish ineffective strategies
– Clients track performance
– Clients report back to coach
– Together, reevaluate based on outcomes
– Coach client to make change or stick with plan
May 13, 2016 46
Re-evaluation and Follow-up
Planning and SupportSelf-Learning
Self-Management
Self-Advocacy
Intake and Evaluation
Coaching Phases
May 13, 2016 47
• Interview using the College Survey for Students with Brain Injury (CSS-BI, Kennedy & Krause, 2009)
– Academic experiences, goals
– Vocational goals
– Medical history
– Academic history
• [Review of documentation/medical history of brain injury
• Gather other neuropsychological reports
• Supplement testing to determine strengths and weaknesses]
Example of an Intake and Evaluation of Student with Brain Injury
May 13, 2016 48
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Evaluating functional executive functions
• Obtained NP report• Controlled Oral Word
Association Test• Wechsler Adult Test of
Reading• Functional Assessment of
Verbal Reasoning & Executive System - Student
• CSS-BI &/or LASSI interview– Academic experiences– Strategies – learning,
organizational, advocacy– Goals
• Compare recall with and without taking notes
– Made predictions
• Predit how long it would take to complete tasks vs. how long it took, with goal of improving predictions
May 13, 2016 49
5-point Likert rating scalestrongly disagree disagree neither agree strongly agree
1. Others do not understand my problems.***
2. I have to review material more than I used to. ***
3. I forget what has been said in class.*
4. I don’t always understand instructions for assignments.*
5. I get overwhelmed in class. *
6. I have trouble prioritizing assignments & meeting deadlines.*
CSS-BI Academic challenges: To what extent do you agree with the following statements about your
experience as a college student since your injury?
May 13, 2016 50
7. I have fewer friends than before.*
8. I have trouble managing my time.*
9. I get overwhelmed when studying.
10. I procrastinate on things I need to do.
11. I get nervous before tests.
12. I have trouble paying attention in class or while studying.
13. I am late to class.
May 13, 2016
Kennedy, Krause, & O’Brien, 2014
51
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College Survey for Students with Brain Injury
(CSS-BI)
May 13, 2016
Organizing, managing
Studying, learning
Psychosocial
Nervousness
Kennedy et al., 2008, 2014
52
I have to review material more than I used to.
Agree:
Give example?
How do you review? Or What do you do to review?
• May need to give example, e.g., highlight?
I don’t always understand instructions
Agree:
Give example?
What do you do when you don’t understand?
* May need to give example, e.g., check syllabus, ask peer
I have fewer friends than before
Uncertain:
So you are uncertain about this?
• Yeah well, I don’t really have fewer friends, but I have different friends, better friends
Interviewing procedures
May 13, 2016 53
Interpreting strengths & weakness
I am able to: Examples of this are:
1. Pay attention 1. I stay focused in class
2. I can study for long periods of time
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I have trouble with: Examples of this are:
1. Dysinhibition, inability to ‘wait’ 1. I ask too many answers to questions in class
2. I don’t always weigh consequences before making decisions
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Domain overlap
Self-learning
Self-management
Self-advocacy
Nervousness
May 13, 2016
1
2
55
Teach them self-regulation
Goal –
Self-monitor
Strategy decision – Self-control
Implement strategy
Compare (& adjust)
Metacognitive beliefs &
Sense of self
May 13, 2016
Revised from Flavell, 1979; Kennedy & Coelho, 2005
56
Identify potential
goals
Select doable goal
Identify potential
strategies, solutions
Select optimal
strategy; back-up
Learn the strategy
Create steps,
materials
Initiate strategy
steps
Track strategy use
Track perfor-mance
Compare to goal, review
Adjust goal, adjust
strategy
Apply to other situations
Goals
Implement Strategies
Adjust
Self-regulation process for complex activities
Kennedy & O’Brien, 2016
May 13, 2016 57
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Value is in the process, not just the product
May 13, 2016
• Internal process - problem or activity based (Goal, Strategy, Adjust – GSA)
• External process – weekly sessions of persisting in problem solving, support, adjusting that models and builds resiliency
58
Performance & Self-Regulation Goals
Performance goals are appealing because they are written to be measurable and specific to identified situations
• “…will recall 4 out of 5 details from orally presented story after 5 minute delay across 3 sessions”
However, these target only the level of theskill and not changes in self-regulation
• Also do not explicitly activate the self-regulation loop to allow for an updated understanding and awareness of the skill
May 13, 2016 59
Self-Regulation Goals
Often attainable, even when performance goals
may not be
Target the client’s ability to monitor their own progress toward the
performance goal
With improved monitoring, the client can
become involved in the problem-solving process
of the therapy plan
Clients can suggest strategies and evaluate their effectiveness at
improving performance
May 13, 2016 60
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• Individualized scaling system
• Allows clinicians and clients to: – develop goals together
– quantify progress toward reaching the goals
– Rating scale with 5 levels of achievement
• Demonstrated to be useful for people with TBI with complex executive function tasks such as financial management (Grant, Ponsford, & Bennett, 2012)
Goal Attainment Scaling (Malec and colleagues)
May 13, 2016 61
147
clinicians and clients not only to develop goals together, but also to quantify progress toward
reaching the goals, using a rating scale with 5 levels of achievement. It has been demonstrated
to be useful for people with TBI with complex executive function tasks such as financial
management (Grant, Ponsford, & Bennett, 2012).
Table 2. A goal attainment scaling example that a college student with TBI and the SLP coach
created together
Goal Area: Reading Journal
5 Writing summaries of all chapters read. Effectiveness of notes in triggering
recall is consistent, resulting in rich, specific recall of events and characters. Scanning of the book is limited to only specific scenarios (such as using quotes for an essay). Notes are well elaborated and allow for integration of ideas across the narrative.
4 Writing summaries of all chapters read. Effectiveness of notes in triggering recall is fairly consistent, so that only minimal scanning of the book is needed to recall details. Notes are well elaborated.
Target 3 Writing summaries of most, but not all chapters read. Alternatively, all chapters have notes, but effectiveness of notes in triggering recall is inconsistent. Some time is spent scanning the book rather than relying on summaries.
Starting Point
2 Writing summaries of only a few chapters. Effectiveness of notes in triggering recall is inconsistent. More time is spent scanning the book than relying on summaries.
1 Writing summaries of chapters read only rarely or not at all.
As an example of GAS, a college student with TBI scaled goals with the guidance of his
clinician. This student had severe declarative memory impairments but strong executive
function abilities. As a result of his memory deficits, he was having difficulty recalling a novel
he read for a literature class. Each time he began the week’s reading assignment, he was
unclear about what had already occurred and found himself rereading previous chapters. In a previous semester, he had to complete a weekly journal of his reading, so he thought a journal
might help with this as well. The goal to complete journal entries for each chapter that would
trigger accurate and effective recall was set and scaled from 1 to 5 (see Table 2). Using GAS,
baseline is set at a level 2, describing his current performance but allowing for some backward
movement. The goal is initially set at level 3, with levels 4 and 5 showing further improvement.
Each week, he ranked his own performance and compared it to the coach’s rating. This student progressed to a 5 over a period of 3 weeks and maintained this when he began a second novel.
Thus, this highly adaptable scale allows both the client and clinician to track and monitor
progress over time.
This focus on process also allows clinicians and clients to consider the cost-benefit
trade-off of multiple PCOs that a focus on outcomes alone would not. For one college student, her goal to earn a 4.0 GPA was problematic because it required her to eliminate nearly all other
aspects of college life. She studied constantly, rarely interacted with roommates, was involved
in no extracurricular activities, and repeatedly checked her work to excess; all of this had a
side effect of bouts of anxiety and self-doubt. More appropriate goals for her instead focused on
engaging in activities that she enjoyed and establishing social networks at college. Although it
took two semesters of her constant study habits to convince her that these other goals were in her best interest, she eventually lowered her academic expectations to allow these other goals
to be addressed. As a result of her new goals, grades did indeed decline in some classes, but
the trade-off was that she had time and energy to participate in social activities (e.g., being in a
school musical, moving to an apartment with friends) while maintaining a positive outlook, all
Sample Scaled Goal
May 13, 2016 62
Management as a Core Skill
Studying/learning
Self-advocacy
Manage-ment
Stress/anxiety
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Kennedy et al., 2014
63
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Self-Learning (SL)
Grade based: want to get a B
Process based: Write better papers; use keywords
Develop strategies for taking multiple
choice tests
Self-Management
(SM)
Turn in all my papers on time
Keep up with a long term project instead of waiting
until the end
Prioritize assignments to work efficiently
Self-Advocacy
(SA)
Discuss my brain injury with my
professors
Find more activities that I can
still do with my friends
Become a part of a class study group
Coaching measurable goals
May 13, 2016 64
Self-management: Goal generation
Problem Performancegoal
Self-regulation goal
Coaching
It should only take me 2 hours a week to read assigned readings, but am not sure… I don’t know how to plan.
Student will keep up with reading & turn in assignments on time.
1. Student will accurately assess how long it takes to read.
2. Student will accurately assess how long it takes to complete assignment.
Strategy: 1. Instruct in ‘Plan-do-review’2. Provide form3. Student tracks4. Discuss impact on planning
May 13, 2016 65
Plan Do Review
May 13, 2016 66
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Plan-Do-Review
May 13, 2016 67
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Self-Learning & Studying: Strategy & goal development
Problem Performancegoal
Self-regulationGoals
Coaching
Student: Reading a novel, I can’t recall what I read yesterday so I don’t understand next chapter
Recall a sufficient amount that he already read, so he could continue to read/understand.
1. To create a scale to assess how well I do.
2. To implement the journaling strategy.
3. To self-assess my recall, reading using the scale
Coach: Show me what you mean. What do you think you should do?
Student: I could ‘journal’ my reading as I go like I learned last semester.
Coach: Lets have you create a way for you to assess.
May 13, 2016 69
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Self-learning & Studying: Strategy
Performance goal
• To be able to review (& recall) what's been said in class.
Self-regulation goal: Strategy/Execution goal
1. Student will record lectures while taking notes using LiveScribe(SmartPen) & track use
2. Student will review lectures prior to quizzes
May 13, 2016 70
Self-learning & Studying: Strategy, Implement, Adjust
1. Strategy – Live Scribe
Learn Pen
Use in class
Review notes
Hard to take notes
Draw images in class
2. Performance - Recall
Draw images
Use in class
Review images/listen
Easier to use
Recalls lecture material
May 13, 2016 71
Self-Advocacy: Creating a Team
May 13, 2016 72
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Self-Advocacy: Implementation
Problem Performancegoal
Self-regulation goal
Coaching
“I get really nervous before exams. I am easily distracted”
Reduce experience of nervousness
1. Implement her accommodation to take exams in Disability services office
Coach: And this nervousness is since your injury? Student: Yeah. Coach: You could try to taking the exam in the DS office, right? Student: its seems like a hassle, and I don’t know, I just don’t like going thereCoach: But fewer distractions likely?
May 13, 2016 73
• Problematic goal for student to earn a 4.0
– Capable … but at cost of studying constantly, no extracurricular activities, would not socialize with roommates, repeatedly checked her work to excess
– Side effect - anxiety, self-doubt
• Set goals to engage in activities that she enjoyed and establish social networks at college
– Got a lead in local production of ‘Fiddler on the Roof’
• Lowered her academic expectations to allow these other goals to be addressed
Self-Advocacy Goal: Benefits, Costs
May 13, 2016 74
• Slight decline in grades, but had time and energy to participate in social activities (e.g., being in a school musical, moving to an apartment with friends)
• Maintained a positive outlook
• Grades alone do not tell the whole story – outcomes must measures the student beyond the classroom
– The back story
Self-Advocacy Goal: Benefits, Costs
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• Students will track their own performance on daily (weekly) basis
• Discuss with coach the factors that may be affecting performance
• Also discuss/rate:
– Effort
– Effectiveness of strategies
– Development of routines
Implementation goals: Self-tracking Implementation
May 13, 2016 76
Tracking Strategy Use
May 13, 2016 77
May 13, 2016
Form 4.X
Strategy Review and Application
Consider the strategies you are now adding to your toolbox. List these and identify other situations or activities in which you could use these strategies.
Strategy
Domain: SM, SL, SA
Current Use Other Uses
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May 13, 2016
FORM 4.X
Strategy Usefulness and Next Steps This form can help you figure out what happened when you implemented the plan or strategy. You can also consider your options. Write out the strategy, describe what happened, consider your options and identify what you want to do next.
Goal:
Strategy or Plan:
Did you use it enough so you can tell if it worked?
Yes No
Describe how well it worked: Describe barriers that interfered:
What is your plan? What is your plan?
___________________________
___________________________
___________________________
___________________________
__________________________
__________________________
__________________________
__________________________
Continue to use it as is & assess its usefulness
Continue to use it, but consider ways to make it easier, effortless
Discontinue its use (& why) & select a
different strategy
Discontinue its use, change your goal, figure out impact
Do nothing different & try again
Deal with barriers & try again
Use a different strategy, if so, what?
Have a backup strategy if barriers return
Change your goal, figure out impact 79
Portfolio – Table of Contents
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Supporting Executive Functions in Students with TBI by Coaching Self-regulation
• Work with transition teams
• Educate & translate impairments
• Educate in role of DS, college culture
• Explicitly instruct students in self-regulation– Monitoring/setting goals– Instruct in strategies– Implement– Adjust
• Students choose goals, strategies, ways to implement
• Domains of: – Time management,
organization– Studying and learning– Self-advocacy – identify
‘go-to’ supporters
• Have students create portfolio or toolboxes
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Resources
On-line
• www.ancds.org - Practice guideline publications on cognitive rehabilitation therapy for persons with TBI
• www.LearnNet.org – NY educational website
• www.thinkcollege.net - Think College!• www.brainline.org – resources about
TBI • www.cbirt.org – Center for Brain Injury
Research & Training– http://media.cbirt.org/uploads/2012/1
0/Transition_Toolkit_October_2012.pdf.
• www.neurocognitivelab.com –Kennedy’s website– http://neurocognitivelab.com/wp-
content/uploads/2015/09/Disability-specialist-document_final.pdf
Manuals & Books
• Collaborative brain injury intervention: Positive everyday routines. Ylvisaker & Feeney, 1998, Singular Publishing.
• Optimizing Cognitive Rehabilitation: Effective Instructional Practices, Sohlberg & Turkstra, 2011, Guilford Press.
• “Transitions” series, Brook’s Publishers
• Coaching Students with Executive Skills Deficits, Dawson & Guare, 2011, Guilford Press.
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Thank you!
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www.neurocognitivelab.com
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References• Carver & Scheier (1991). Self-regulation and the self. In J. Strauss & G.R. Goethals (Eds.), The
Self: Interdisciplinary Approaches (pp168-207). New York: Springer-Verlag.
• Cicerone, K., Dahlberg, C, Kalmar, K., Langenbahn, D., Malec, J., Bergquist, T., et al. (2000). Evidence-based cognitive rehabilitation: Recommendations for clinical practice. Archives of Physical Medicine and Rehabilitation, 81, 1596–1615.
• Flavell, J.H. (1979). Metacognition and cognitive monitoring: A new area of cognitive-developmental inquiry. American Psychologist, 34, 906-911.
• Kennedy, M. R. T. & Coelho, C. (2005). Self-regulation after traumatic brain injury: A framework for intervention of memory and problem solving. Seminars in Speech and Language, 26, 242-255.
• Kennedy MRT & Krause MO (2010). Academic experiences of adults with and without traumatic brain injury using the College Survey for Students with Brain Injury (CSS-BI). Brain Injury, 24, 325.
• Kennedy, M.R.T., Krause, M.O., & O’Brien, K. (2014). Psychometric Properties of the College Survey for Students with Brain Injury: Individuals with and without Traumatic Brain Injury, Brain Injury. DOI: 10.3109/02699052.2014.920520
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References• Kennedy, M. R. T., Krause, M. O., & Turkstra, L. S. (2008). An electronic survey about college
experiences after traumatic brain injury. NeuroRehabilitation, 23(6), 511-520.
• Kennedy, M.R.T. & O’Brien, K.O. (in preparation, 2016). Coaching college students with executive dysfunction: A dynamic approach. NY: Guilford Publishing.
• Kohler, P. D. (1996). Taxonomy for Transition Programming: Linking research and practice. Champaign, IL: Transition Research Institute at University of Illinois at Urbana-Champaign.
• Mealings M, Douglas J, Olver J. Considering the student perspec- tive in returning to school after TBI: A literature review. Brain Injury 2012;26:1165–1176.
• National Secondary Transition Technical Assistance Center NSTTAC. (2010). Evidence-based Secondary Transition Practices. Retrieved from http://www.nsttac.org/ebp/evidence_based_practices.aspx
• O’Neil-Pirozzi, T., Kennedy, M.R.T., & Sohlberg, M.M. (in press). Evidence-based practice for the use of internal strategies as a memory compensation technique after brain injury: A systematic review. Journal of Head Trauma Rehabilitation.
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References• Raue, K., & Lewis, L. (2011). Students with disabilities at degree-granting postsecondary
institutions. (NCES 2011–018). U.S. Department of Education, National Center for Education Statistics. Washington, DC: U.S. Government Printing Office.
• Sitzman & Ely, 2011, Psychological Bulletin, 137, 3, 421–442.
• Stuss, D., & Benson, D. F. (1986). The frontal lobes. New York, NY: Raven Press
• Tate, R., Kennedy, M.R.T., Bayley, M., Bragge, P., Douglas, J., Kita, M., Ponsford, J., et al. (2014). INCOG Recommendations for Management of Cognition following Traumatic Brain Injury Part VI: Executive Function and Self-awareness, Journal of Head Trauma Rehabilitation, 29(4), 338-352.
• Todis B, Glang A. Redefining success: Results of a qualitative study of postsecondary transition outcomes for youth with traumatic brain injury. Journal of Head Trauma Rehabilitation 2008;23:252–263.
• Willmott C, Ponsford J, Downing M, Carty M. 2014. Frequency and quality of return to study following traumatic brain injury. The Journal of Head Trauma Rehabilitation 2014;29:248–256.
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