Transcript Strategies & Interventions - Traumatic Brain Injury

Brain Injury and Executive Functioning
Rachel Toplis, PhD
Dr. 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 setting
 Planning/organizing
 Initiating
 Inhibiting
 Self-monitoring and evaluating
 Strategic thinking
 Flexible 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 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
What disabilities are impacted by
dysexecutive functioning?
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Traumatic Brain
Injury
Specific Learning
Disability
Attention Deficit /
Hyperactivity
Disorder
Autism
Tourette’s Syndrome
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Schizophrenia
Depression
Obsessive
Compulsive
Disorder
Dementia
Etc…..
Development of Executive
Functioning
Attention and Self Control
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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
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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
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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
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
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.

Scattered,
disorganized
approach to solving a
problem, easily
overwhelmed by large
tasks or assignments.

Self Monitoring –
Checking one’s own
actions during, or
shortly after finishing
the task / activity to
assure appropriate
attainment of goal.

Does not check for
mistakes, unaware of
her own behavior and
its impact on others.
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.
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 Structure
 Manage 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
 Rehearse and
 Pre-teach
review new
information
frequently.
 New information
should be
concrete and
memorable.
 Printed list of daily
activities,
locations, and
materials needed.
framework for new
information and
guide attention to
important parts.
 Rate of presentation
may need to be
altered.
 Information broken
down into smaller
chunks.
Working Memory
 Student
Based
 Practice, practice,
 Visual Imagery.
practice.
 Encourage verbal
rehearsal/self-talk.
 Write a checklist
of steps.
 Learn ‘active
listening’
techniques.
 Teach to chunk
information.
 Use rehearsal,
repetition and
paraphrase.
 Provide study
outlines
Planning
 ExternalStructure
 Provide examples
 “Cookbook” of
of how students
might plan
differently to
reach the same
goal.
 Overtly teach goal
setting
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 issue
 2. State the reason
 3. Offer a strategy
 4. 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
 Folders and
from adult to
organize
materials.
 ‘Organization
time’ at the
beginning and /
or end of the day.
planners
 Writing
checklists.
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
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 Focus
 Self monitoring tasks.
 Getting students attention.
○ Auditory signals (ring bell, clap pattern,
verbal signal ‘freeze’).
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.
Attention and Focus
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Limit Noise
Remove distractions
Provide concrete
visual cues
Limit amount of info
on a page.
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Adjust assignments.
Focus on most
salient aspect of
lesson.
Maintain brisk pace.
Repeat instructions
Attention and Focus
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Use short and
concise instructions.
Reinforce on-task
behavior.
Give frequent
breaks.
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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 & 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.
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/informationmatrix/

LearNet: www.bianys.org/learnet
 Resources for providing interventions and
accommodations for a child with a brain injury.
Resources for Presentation
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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.