Practical Strategies for Managing Executive Function Impairments

in Students with TBI

McKay Moore Sohlberg, PhD, CCC-SLPBryan Ness, M.S., CCC-SLPUniversity of OregonCommunication Disorders & Sciences Dept

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?

Executive Functions

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

Executive Functions: Functional Definition Self-awareness of strengths and Self-awareness of strengths and

limitations (what’s hard to do; what’s limitations (what’s hard to do; what’s easy to do)easy to do)

Goal settingGoal setting Planning/organizingPlanning/organizing InitiatingInitiating InhibitingInhibiting Self-monitoring and evaluatingSelf-monitoring and evaluating Strategic thinkingStrategic thinking Flexible shifting, adjusting, benefiting Flexible shifting, adjusting, benefiting

from feedbackfrom feedback

(Feeney, 2005)

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)

Executive Functions Symptoms (Dysexecutive Syndrome)

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

(Feeney, 2005)

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.

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.

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

Common misperceptionsThe 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)

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)

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)

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.

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

Examples of External Aids

High Tech/Multipurpose PDA Computer

Time Management Timex Data Link Watch Kitchen timers Day planner

Example of External Aid (cont)

Task Specific Checklist (homework, materials,

readiness routine) Pager system Color coding/labeling

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

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

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 andmotivation on checklist

Student self rates success during and after task and documents successful strategies

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

Examples of Environmental Modification-physical set up

Seating Desk Barriers (ear plugs/head set) Desk set up (no irrelevant items) Paper handling systems

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

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

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

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

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

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.

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 experimentationPlan A - Plan B - Plan C

Testing time line)

The Plan B Approach:

OCHTA (modified from Yvilsaker & Feeney)

1. Observe in…2. Context

3. Hypotheses generation4. Test hypotheses

5. Assess outcomes; modify program

Example:Step Comments

Observe-define problem

Teacher: Not turning in assignments.Parent: Not seeing homework done at home/student reports she doesn’t have any.

Generate hypothesis

Not recording/getting homework in backpack …OR…Doesn’t initiate homework

Testhypothesis

Develop homework survey for parent & teacher to determine breakdown--find out it is a tracking problem

ImplementIntervention

Model, teach, and drill homework tracking system. Parents, teachers and student are aware of the system and collaborate on data collection

Evaluate outcome

Log data show increased homework follow-through. System was easy to use.

Modify… Repeat steps 1-5 if necessary

Case Examples

Practice applying OCHTA to EF interventions.