Practical Strategies for Managing Executive Function Impairments in Students with TBI

1. Practical Strategies for Managing Executive Function Impairments in Students with TBI McKay Moore Sohlberg, PhD, CCC-SLP Bryan Ness, M.S., CCC-SLP University of Oregon Communication Disorders & Sciences Dept

2. Outline • What are executive functions? • What are the signs of executive function impairment? • What are the school-related effects of executive function impairment? • What are the best ways to reduce the adverse effects of executive function impairment on school performance?

3. Executive Functions “… those mental capacities necessary for formulating goals, planning how to achieve them, and carrying out the plans effectively” (Lezak, 1982)

4. Executive Functions: Functional Definition (Feeney, 2005) • Self-awareness of strengths and limitations (what’s hard to do; what’s easy to do) • Goal setting • Planning/organizing • Initiating • Inhibiting • Self-monitoring and evaluating • Strategic thinking • Flexible shifting, adjusting, benefiting from feedback

5. One More Definition…(Sohlberg & Mateer 2002) • Starting behavior (initiation) • Stopping behavior (controlling impulsivity) • Maintaining behavior (task persistence) • Sequencing & time behavior (organization) • Creativity, fluency, problem solving (generative thinking) • Self evaluation & insight (Awareness)

6. impulsiveness poor social judgment social disinhibition Egocentrism difficulty interpreting the behavior of others Perseveration poorly regulated attention disorganization (in thinking, talking, and acting) weak goal formulation ineffective planning decreased flexibility/ shifting slowed processing diminished divergent thinking concrete thinking immature problem solving weak self-monitoring inefficient responses to feedback/ consequences reduced initiation dulled emotional responses Executive Functions Symptoms (Dysexecutive Syndrome) (Feeney, 2005)

7. DES and Brain injury • Traumatic brain injury (TBI) • Frontal lobes are responsible for regulating executive functions. • These areas are prone to direct or indirect impact during accidents.

8. Other populations that exhibit executive function impairment • Attention Deficit and Hyperactivity Disorder (ADHD) • Impaired response control and sustained attention • Autism • Impaired task switching (i.e. perseveration) • Learning Disability • Working memory deficits and reduced strategy use.

9. Examples of classroom impact • Assignment management • Unable to recall assignments • Difficulty gathering/organizing materials • Difficulty starting and remaining engaged in work • In-class behavior regulation • Difficulty staying “on task” • Struggle to transition from one activity to another • Mathematics • Difficulty sequencing multi-step procedures • Reduced performance monitoring • Writing • Difficulty planning a narrative

10. Common misperceptions The child with DES… • is “lazy”(initiation disorder) • has an intellectual impairment (may have preserved language/cognition & ef impairments get in the way) • is noncompliant (organization or awareness issues)

11. Developmental Overlay of TBI • Effects of brain injury in children are particularly profound because the injury occurs to a developing brain (Welsh & Pennington, 1988) • Recovery is superimposed on normal developmental processes, impacting previously learned skills and the development of future skills (Ewing-Cobbs et al., 1997)

12. Developmental Overlay of TBI • Full effects of an earlier injury may not be evident until adolescence when children are expected to demonstrate increasing competence in executive functions and reasoning. • Skills may not develop if the relevant areas of the brain have been damaged (Alden & Taylor, 1997; Feeney & Ylvisaker, 1995; Mangeot et al, 2002; Ylvisaker & Feeney, 2002)

13. Developmental Overlay of TBI • Children may also develop deficits in the social and behavioral domains secondary to these cognitive deficits. • For example, primary deficits in executive functions have implications for the child’s behavior in the classroom and peer relationships. Such secondary deficits may become more pronounced in a child injured at an earlier age.

14. Management Approaches An executive function “Toolkit” • Use of external aids • Use of a metacognitive strategy • Environmental modifications (e.g, task accommodation, setting up routines) • Training of Natural Supports

15. Examples of External Aids • High Tech/Multipurpose • PDA • Computer • Time Management • Timex Data Link Watch • Kitchen timers • Day planner

16. Example of External Aid (cont) • Task Specific • Checklist (homework, materials, readiness routine) • Pager system • Color coding/labeling

18. TEACH-M! Task analysis: Know your content. What is the target skill? Break it into small steps. Chain steps together. Errorless learning: Keep errors to a minimum during the acquisition phase. Model target step(s) BEFORE client attempts a new skill/step. Carefully fade support. Don’t let an error sneak by! Demonstrate the correct skill/step right away and ask client to do it again. Assess performance: (initial)-assess skills before treatment; (on-going) - probe performance at the beginning of teaching session and/or before introducing a new step. Cumulative review: Regularly review previously learned skills. High rates of correct, practice trials: 5 trials is not enough! 30-50 or more is like it! Massed practice then spaced retrieval Metacognitive strategy training: self-evaluation of one’s own performance

19. Examples of Metacognitive strategies • Self-monitoring of Attention • Regularly monitor degree of attentiveness. • Can use timers, clocks, or teacher/parent prompts. • Self-evaluate attentiveness using rating scales and chart data for motivation

20. Examples of Metacognitive strategies • Self-monitoring of Performance • Monitoring progress and/or success during an activity • Step-by-step task-specific checklists can be used to support difficult tasks • May include error checking and motivation on checklist • Student self rates success during and after task and documents successful strategies

22. Examples of Metacognitive Strategies • Self-talk/Self-regulation • A repeatable phrase or narrative to help guide the student through tasks • Directions for specific activities (e.g. math problem) or general “on-task” routines • Can be triggered by an external aid (e.g. timer) or teacher/parent prompt

24. Examples of Environmental Modification-physical set up • Seating • Desk Barriers (ear plugs/head set) • Desk set up (no irrelevant items) • Paper handling systems

25. Environmental Modification-Task Accommodation • Structure tasks in step by step format • Give one portion of a task at a time • Routinize tasks • Put time estimate at the top of the paper • Assign peer buddy

26. Natural Supports • Modification of instructional style to accommodate student • Education about nature of executive functions w/resulting modification of expectations & change in management approach • Facilitation of supportive social environment

27. Combination approaches • External aid + metacognitive • Digital timer and self-talk routine • Natural supports + external aid • Classroom/school wide culture and assignment completion systems • Environmental modification + metacognitive • Task accommodation and ask for help

28. For any strategy, think about… • Selection • The child’s personal preference • Cost • Ease of use • Training • TEACH-M model • Measuring impact • What is the target? • Homework completion, writing skills, on-task… • Supporting Use • Communication: teachers, support staff, parents must know the strategy

29. How do you know which tool to select? (not just for DES)

30. There are two plans… -Plan A: Oh, let’s a just give it a whirl and see what happens! OR -Plan B: Observe behavior, think through intervention options, systematically apply these and evaluate to determine effectiveness.

31. The Plan B Approach: What’s the problem? (Using the two strangers in the doorway rule) Hypothesis Formulation (Why is s/he doing this?) Generate Assessment (Begin with easiest to test or most obvious) Implement Strategy/ Evaluate Outcome (Protocol for experimentation Plan A - Plan B - Plan C Testing time line)

32. OCHTA (modified from Yvilsaker & Feeney) • Observe in… • Context 3. Hypotheses generation 4. Test hypotheses 5. Assess outcomes; modify program

33. Example:

34. Case Examples • Practice applying OCHTA to EF interventions.