Maximizing Executive Function After Brain Injury

1. Brain Injury and Executive Functioning Rachel Toplis, PhD Dr. Jonelle Neighbor Strategies & Interventions

2. 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. wwline.orw.ldong

3. 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!

4. 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.

5. Executive Functions: Functional Definition • 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 (Feeney, 2005)

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

7. Executive Functioning Difficulties SOCIAL: • 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

8. 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…..

9. Development of Executive Functioning

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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.

16. 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.

17. 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.

18. 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.

19. 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.

20. 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.

21. Inhibit • External Structure • Provide 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.

22. 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

23. 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.

24. 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).

25. Emotional Control • External Structure • Manage antecedents. • Model appropriate behavior. • If student responds with emotional outburst to school work, consider returning to mastery level or adjust academic demands.

26. 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.

27. 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.

28. 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.

29. 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.

30. 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

31. 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

32. 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.

33. 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 issue • 2. State the reason • 3. Offer a strategy • 4. General reassurance.

34. 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”.

35. 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

36. 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.

37. Self Monitoring • External Structure • Provide 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

38. 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

39. 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?

40. 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?

41. 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?

42. 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.

43. 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.

44. 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.

45. Attention and Focus • Self monitoring tasks. • Getting students attention. • Auditory signals (ring bell, clap pattern, verbal signal ‘freeze’).

46. Attention and Focus • Maintaining 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.

47. 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

48. 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)

49. Great Resource • www.cokidswithbraininjury.com • www.cokidswithbraininjury.com/information-matrix/

50. Resources • BrainSTARS Brain Injury: Strategies for Teams and Re-education for Students. • Dise-Lewis, Lohr Calery & Lewis • Hands 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.