Challenging Behaviors: Assessment and Intervention Strategies Laura A. Flashman, Ph.D., ABPP Department of

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Transcript Challenging Behaviors: Assessment and Intervention Strategies Laura A. Flashman, Ph.D., ABPP Department of

Challenging Behaviors: Assessment
and Intervention Strategies
Laura A. Flashman, Ph.D., ABPP
Associate Professor of Psychiatry
Neuropsychiatry Section, Neuropsychology Program and
Brain Imaging Laboratory, Department of
Psychiatry,Dartmouth-Hitchcock Medical Center,
Lebanon, NH
& New Hampshire Hospital, Concord, NH
What are “Challenging Behaviors”?
 Related
to Personality Changes
– Impulsivity, Intrusiveness, Poor Boundaries,
Irritability, Emotional Lability, Low Frustration
 Aggression
– Self injurious behavior, hurting others
What are “Challenging Behaviors”?
 Related
to “Deficit Syndromes”
– Isolation, withdrawal, apathy, low motivation
 Related
to Cognitive Changes
– Poor judgment, inability to comprehend
consequences, poor decision making,
perseveration, impaired memory and
concentration, difficulty adjusting to the
Ways to Deal with
Challenging Behaviors
 Medications
 Behavioral
 Cognitive
Applied Behavioral Analysis (ABA)
 Goal:
To increase or decrease a particular
behavior, to improve the quality of a behavior, to
stop an old behavior or teach a new behavior
 General
Uses: Can address a broad spectrum
of human behavior
– Increasing productivity in the workplace
– Teaching children
– Precise training of military personnel
– In our case, handle the challenging behaviors
associated with TBI
Seven Essential Elements of an
ABA-based Program (Baer, Wolf & Risely (1967)
Must be applied (i.e., behaviors focusing on
should have some social significance).
Must be behavioral (i.e., environment and
physical events should be recorded with
Must be analytic (i.e., convincing evidence that
the intervention is responsible for the change in
Must be technological (i.e., techniques could be
duplicated by another).
Seven Essential Elements of an
ABA-based Program
Must be conceptually systematic (i.e., there
should be relevance to established and
accepted principles).
Must be effective (i.e., should seek to change
the targeted behavior to a meaningful degree).
Should display some generalizability (i.e.,
seen in a variety of settings or to related
Six Steps for a Solid
Applied Behavioral Analysis
Identify Target Behaviors
Measure the Behavior
Analyze the Behavior – A B C’s
Develop an Intervention
Program Generalization of the Behavior
Empirically Evaluate the Results
Behavioral Terminology
 Behavior
– any observable and measurable
Behavior – the particular behavior
you have identified for change
 Target
assessment – a description of
the frequency, duration, and conditions
related to a target behavior
 Behavioral
Identification of Target Behavior(s)
 Choose
your battles
 Start
with reasonable goals (“3 shall be
the number”)
 Track
Once the Target Behavior is
 We
need to learn all we can about this
 Is it a behavior we want to increase?
 Is it a behavior we want to replace?
– Inadequate in meeting an individual’s
– Inappropriate in the current environment?
Behavior “Modification”
 Modification
of behavior is most effective if
the motivation behind the behavior can be
 Once
motivation is known, once we
understand the need that the individual is
trying to meet, we can develop and teach a
more appropriate replacement behavior
Available Tools of ABA
 Functional
Behavioral Assessment: a precise
description of a behavior, its content and its
 Goal: Better understand the behavior and the
factors that influence it
 Starts with a Baseline Period – a specified time
period when the frequency, duration, or intensity
of the target behavior is tracked prior to the
implementation of an intervention
Behavioral Terminology: The ABCs of ABA
Antecedent: the stimulus or situation to
which the individual responds
Behavior: the behavior (target behavior)
we see exhibited by the individual
Consequence: the stimulus or stimuli
that the individual receives, or that s/he is
stopped being subjected to, as a result of
the behavior
Functional Behavioral Analysis
 Begins
as an assessment, but includes
the step of systematically altering the
antecedents to and consequences of
the behavior to determine which are the
driving forces behind the behavior
Functional Behavioral Analysis
 The
first step: Carefully observe and precisely
describe the behavior the individual is
exhibiting, and the events and stimuli in the
environment both BEFORE and AFTER that
behavior (i.e., Identify the ABCs)
 Observe
and describe the behavior across a
wide sample of environments and occasions
Functional Behavioral Analysis
 The
second step: Look for trends in the occurrences
of the behavior, for stimuli that may be evoking it, or
the needs the individual is attempting to fill by
exhibiting this behavior
Form hypotheses about the behavior and the function
it is fulfilling
Challenge these hypotheses by systematically altering
the environment to determine which are influencing the
Motivations/Purposes of
Challenging Behaviors
 To
gain attention from someone
 To gain a tangible consequence (a treat,
token, money, favorite video, etc).
 To gain a secondary consequence (to get
warmer if one is cold, colder if one is hot, to
gain some sensory consequence)
 To self-regulate one’s emotions (way to calm
down if upset, to raise one’s arousal level if
Motivations/Purposes of
Challenging Behaviors
 To
escape from or avoid an undesirable
– Often in anticipation of a request to work, go to
an activity, communicate, be in an environment
they find uncomfortable, loud, overstimulating,
 To
make a comment or declaration (about
one’s environment, perceptions or emotions)
 To fill a habitual need, in a way that no
longer works
Most Important Factor in
Success of an ABA Program
Behavioral Terminology
Stimulus – the instruction or
environmental cue to which we would like the individual
to respond
 Response – the skill or behavior that is the target of the
 Reinforcing Stimulus – a reward designed to motivate
the individual to respond and respond correctly
 Discriminative
Example: I ask Cathy to get up and get ready for work
in 5 minutes (DS), she does (R), and she gets to watch
TV while eating breakfast (SR).
The Discriminative Stimulus
 A specific
environmental event or condition in
response to which we would like an
individual to exhibit a particular behavior
(teach a person what to do when a particular
thing occurs)
 Goal: Help individual begin to discriminate
certain stimuli from the background noise of
every day life – as something important
The Discriminative Stimulus:
 Make
sure you have the individual’s attention
 Instructions should be simple and clear;
concisely communicate only the most salient
 Be consistent in beginning stages; can be varied
in many settings to encourage flexibility and
generalizability as response occurs more
 Repetition of the instruction should be avoided
(preset limits – e.g., 2 cues, 3 prompts)
The Response
 The
response is the behavior the individual exhibits
after AND AS A RESULT OF the discriminative
stimulus. If person is reacting to other stimuli, need to
look at other factors (environment too distracting,
person not attending?)
Be very clear about what the correct response is
(“Sarah will pick up all the clothes on the floor in her
room and place them in the laundry basket within 1
minute of the request.”)
3 possible responses: Correct, Incorrect, No Response
Correct Responses are Reinforced
 Reinforcing
Stimuli are environmental events
that occur after a behavior that increase the
likelihood of that behavior occurring in the
 Treats,
praise, special privileges, music, trips,
almost anything can be used as reinforcement
if it serves to increase the occurrences of a
particular behavior (positive reinforcement)
Types of Reinforcers
 Primary
Reinforcing Stimuli are unconditioned
– Events or rewards whose value are intrinsically
realized (food, water, warmth, etc)
– Advantages: Value does not need to be taught, will
not extinguish
– Disadvantages: Subject to satiation after relatively
short periods of time, not representative of the natural
Types of Reinforcers
 Secondary
Reinforcing Stimuli are conditioned
– Intrinsically neutral but become reinforcing through association
– Can be social in origin (praise, smiles, sense of accomplishment)
or a token economy (earning tokens (e.g., money) for desirable
behaviors; each one is a step towards acquisition of a primary
– Advantages: more convenient to use, lessens the need for
proximity, more reflective of natural environments, can broaden a
person’s interests, can increase length of time between
presentation of reinforcers (token economy)
– Disadvantage: Need to be taught, must be maintained by
repairing to primary reinforcer to reestablish interest sometimes
Types of Reinforcers
 Positive
Reinforcement: presentation of positive
events after a particular behavior to increase the
likelihood that the behavior will occur in the future
 Negative
Reinforcement: removal of aversive
events after a particular behavior to increase the
likelihood that the behavior will occur in the future
(e.g., alarm goes off, you get up and shut if off,
get ready for work)
Types of Reinforcers
 Differential
Reinforcement: involves reinforcing
almost any positive response (successively
closer approximations of the correct behavior)
to some degree, but providing very strong
reinforcement when the person completely
exhibits the target behavior or skill
4 Types of Punishment
Goal: introduction of negative or removal of
positive stimuli to DECREASE a particular
 Time out: removal of the individual from any
positive stimuli (need to know motivation
behind behavior. If a person screams when
asked to go to work, and he gets put in time
out, behavior may be encouraged, not
4 Types of Punishment
 Extinction:
the withholding of a previously available
consequence (reinforcer) for a response – essentially,
ignoring the behavior, which results in a decrease or
weakening of response rate, duration, or intensity.
Behavior may increase before it decreases.
 Response Cost (token economy): tokens are lost for
occurrences of undesirable behavior.
 Aversive Stimuli: strongly negative behavior introduced
after an undesirable behavior (spanking, scolding). As a
rule, to be avoided, as can do more harm than good.
Alternatives to Punishment
Goal: Reducing difficult behaviors while encouraging more
appropriate behaviors
 Differential reinforcement of other behaviors (DRO):
reinforcement for not engaging in the target for a
specified interval of time (i.e., reading not hitting)
 Differential reinforcement of alternative behaviors:
reinforcement of behaviors which serve as alternative
behaviors to the difficult behavior (i.e., count to 10)
 Differential reinforcement of incompatible behaviors:
reinforcement of behaviors which are incompatible with
difficult behaviors (i.e., can’t be done simultaneously)
Guidelines for Reinforcement
 If
the reinforcement is to be consistent and
effective, the criteria for the response need to be
planned out in detail, understood and used
consistently by all involved in the program
for correct and incorrect responses/
behaviors should be easily distinguishable
reinforcement is being used after correct
behavior, short-lived reinforcers should be used.
Reinforcement Schedules
 Continuous
Reinforcement Schedule: one that
provides reinforcement after every correct response.
Useful for teaching of new behaviors, when goal is
to emphasize relationship between DS and
associated R
 Partial Reinforcement Schedule: one in which only
some instances of the desired response are
reinforced. Often produce more responses at a
faster rate than continuous schedules. Useful for
maintenance of learned behaviors, for increasing the
production of those behaviors once learned, and for
making reinforcement more natural
Token Economies
 Useful
for moving from a continuous reinforcement
schedule, where the individual is rewarded after
each correct/appropriate response, to a schedule
where the individual must make several
appropriate responses before being reinforced.
 Good
for building the ability to delay gratification,
extending an individual’s attention span, increasing
the amount of work produced in a given time
Token Economies
 Provides
a TANGIBLE marker of
 Can
be effective with cognitively
compromised individuals
Teaching Complex Behaviors
 Shaping:
the process by which successively closer
approximations of a behavior are reinforced. Allows
reasonable goals to be set and gives an individual many
chances for success on the way to learning a new
behavior or extinguishing an old, inappropriate behavior
 Step Analysis: breaking down of a target behavior into
smaller, more manageable steps which bring a person
successively closer to that target behavior
 Goal: Complete the first step, get reinforced, master it,
the next step becomes the new goal, etc.
Teaching Complex Behaviors
 Chaining:
the linking of component behaviors
into more complex, composite behavior
 Useful for teaching those behaviors that occur in
essentially the same order each time, and is
especially useful for teaching self-help skills
 Task Analysis: breaking down of a behavior into
its component parts/behaviors
 Example:
Brushing teeth, morning ADLs
Techniques Used in
Behavioral Programs
 Behavioral
momentum: a procedure in which
before asking a patient to do something he/she
is unlikely to do, staff first ask him/her to
perform two simple tasks he/she is likely to do
 Modeling:
a procedure whereby a sample of a
given behavior is presented to an individual to
induce that individual to engage in a similar
Techniques Used in
Behavioral Programs
 Redirection:
a procedure whereby a
patient who exhibits an inappropriate
behavior is prompted to engage in a
more appropriate alternative behavior
Staff Assistance to Maintain Consistency
conflict resolution – a designated time to
channel questions, grievances, and reinforce skills
with specific staff
 Planned
– a procedure whereby a sample of a
given behavior is presented to an individual to
induce that individual to engage in a similar behavior
 Modeling
Generalization of the Behavior
 Generalization:
the application of a behavior or
sill across a number of environments or to a
number of related behaviors
 This
can be very difficulty for individuals with TBI
 Therefore, instructions must be designed to
change over time, in content, and in context, to
help increase generalizability of program
Data Collection
3 Keys to Success with Data:
1. Make the Data Useful
– Helps shape the program, assess the efficacy, look for trends
in behavior
2. Make the Data Relevant to the Goals
– Must be appropriate for the behavior being documented and
for the goals associated with that behavior
3. Make the Data as Painless as Possible
– Find style of data collection that works for you
Data Collection – What to track?
 Frequency:
How often does the behavior occur
over a specific period of time?
– Pd of time chosen depends on behavior being tracked
– Best used when the goal for a plan is to increase or
decrease the occurrences of a behavior
– Example: Mary will decrease the number of times she
approaches the nurses station from 10 to 2 times per
Data Collection – What to track?
 Proportion:
In what percentage of available
opportunities did the behavior occur?
– # of target behaviors that occur in a given # of
– Best used when the goal for a plan is to increase
the quality of a behavior
– Example: Josh will increase his use of his
memory book from approximately 10% of
available occasions to approximately 75% of
Data Collection – What to track?
Duration: For how long did the behavior occur?
– Track for open-ended behaviors that you are trying to increase
– Example: Susie will increase the time she can attend during
work without a prompt from 10 seconds to 3 minutes).
– Can also be used for behaviors one is hoping to decrease or
eliminate, through differential reinforcement of lesser degrees
of behavior (i.e., anger management strategies – how long
before he uses one effectively).
– Example: Mark will use the counting technique to calm himself
when someone tells him he can’t go off the unit, reducing the
length of his tantrums from 3 minutes to 30 seconds.
Data Collection – What to track?
 Intensity:
To what degree was the behavior
– Can be very subjective; best if some degree of
objectivity and specificity can be accomplished
– Rating Scales often used; can be developed:
» 1: Bill shows some aversion to the request but complies
within 10 secs.
» 2. Bill shows significant reluctance, is arguing, and has not
complied within 10 secs.
» 3: Bill attempts to leave the area.
» 4: Bill knocks over a chair or throws something.
» 5: Bill makes physical contact with staff or peers.
Evaluation of the Results
 Feedback
from those implementing plan, and
the individual
 Have we decreased undesirable behaviors?
 Have we increased desirable behaviors, or
replaced undesirable behaviors with more
acceptable behaviors?
 HOW MUCH less frequently, intensely?
 Can the individual apply these behaviors,
strategies in more than one situation?
Evaluation of the Results
 Evaluate,
 Tweak,
evaluate, evaluate
tweak, tweak
 Increase
reinforcement intervals
Neuropsychological Testing
 To
provide information about cognitive
strengths and weaknesses
 To
 To
provide Baseline Measurements
make recommendations for
Treatment & Behavioral Management
What it is not….
testing = IQ
testing =
Academic testing
testing =
Cognitive Rehabilitation
When do you refer for a
neuropsychological evaluation?
 When
there is a question about a person’s overall level
of cognitive ability
 When
there is a question about what role a person’s
cognitive functioning has on his/her behavior
 To
assess for deterioration over time
 To
assess recovery or effectiveness of
 To
plan for cognitive remediation strategies
Potential Issues to be Addressed
 Safety
– Can this person be left alone?
– Can this person drive?
 Independence
– Can this person live alone?
– Can this person manage their own money?
– What supports need to be provided to maximize
independent living/provide the least restrictive
Potential Issues to be Addressed
 Employment
– Can this person work in their previous capacity?
– Can this person work at all?
– In what type of job would this person succeed?
– What accommodations can be made to maximize
Information to be gathered
Problem – what brings them to
testing? Onset and duration, etc of problem
– was there a specific precipitating event?
Course of problem – slow progression, fast
decline, in recovery phase?
 Precipitating
 Impacting
on what every day life situations?
Information to be gathered
Information – from significant others,
caregivers, school when appropriate
 Collateral
– What do they see in terms of impact, where are the
problems, what does the course look like, etc.
 Also
use documentation such as medical
records, school records, previous test scores,
vocational records, such as job evaluations, and
contact with physicians
Behavioral Observations
Used in Planning
 Orientation
signs – problems with speech
(productivity, fluency, prosody, aphasic symptoms,
speed), motor, gait, vision/hearing
 Motivation/Task Persistence/Frustration
 Level of distractibility/ability to follow directions
 Fatigue/Endurance
 Affective Status
 Physical
Cognitive Domains Assessed
During Neuropsychological Evaluation
Visual-spatial functioning
Executive function
Interpretation/Summary of Results
 Quantitative
– Appropriate Norms
– Consideration of an individual’s own baseline
 Qualitative
– Boston Process Approach
– Problem Solving Strategies
– Testing the limits
 One
bad score does not a deficit make
How are Test Results Used?
Depending on the referral question, NP evaluation may:
•Provide a profile of strengths and weaknesses to
guide future services.
* Confirm or clarify contributing factors to the profile.
* Document changes in functioning since prior
examinations, including effects of treatment,
spontaneous recovery.
How are Test Results Used?
*Clarify what compensatory strategies
would help.
* Suggest possible interventions.
* Result in referrals to other specialists.
NP Deficits in TBI
 Acute
(or time limited) NP difficulties
– Arousal, alertness, orientation
– Post-traumatic amnesia
– Aphasia and neglect
 Chronic
(long-term) Impairments
– Attention
– Memory
– Executive functioning, concept formation, planning,
information processing speed
Overview: NP Deficits in TBI
by factors such as:
–Type (penetrating or closed, focal or
–Severity of injury
–Site of injury
–Length of time since injury
–Premorbid level of functioning
Common Cognitive Deficits
following TBI
 Slowed
speed of information processing
 Attention
– Sustained attention
– Attention span
– Divided attention
– Multiple processing
Common Cognitive Deficits
 “Executive
– Reasoning
– Problem solving
– Self-monitoring
– Emotional and behavioral control/ modulation
– Insight and judgment
 Memory
– Working memory
– Short-term and long-term memory
Cognitive Deficits after TBI
 While
cognitive deficits have been reported in all
domains, deficits in attention/concentration,
memory, and executive function are the most
common following TBI due to their diffuse nature
 There
is also significant variability due to more focal
injury. Frontal and temporal lobes are most
 Deficits
generally improve over time, although
persistent deficits are seen after more severe
injuries, and even after mild TBI (PCS)
Deficits resulting from TBI
 Changes
in personality are frequent
due to frontal lobe injury, and can
additionally impact on cognition
 Cognitive
and personality changes can
result in difficulties in interpersonal
relationships, maintaining jobs, and
may lead to legal difficulties
Cognitive Remediation: What is it?
A group of strategies intended to help
persons with cognitive dysfunction to
improve cognitive, perceptual, psychomotor
and behavioral skills.
GOAL: To improve the individual's ability to
function in work, academic, and community
living environments.
Restorative Model
Views the brain as “plastic”
Practicing a task that requires a particular cognitive
skill results in improvement and allows the
individual to generalize the learned skill to similar
tasks or tests of cognitive functioning
Individual learns cognitive skills by performing a
variety of tasks
Restorative Model
Shows some utility in treatment of more basic
or fundamental abilities such as attention,
concentration, and mental speed
Problem: lack of generalizability between
tasks performed in treatment and the
expression of the skill in daily life
MODEL: Compensatory Model
Presence of impairment is taken as a given and
the individual is taught how to perform specific
functions in a new way, taking into account the
individual’s strengths and weaknesses
Focus on facilitating the return of functional
activities by substituting an impaired function of a
more intact ability
MODEL: Compensatory Model
Helps individual to anticipate how their deficit
may effect their functioning and develop
strategies to compensate for them.
Requires adequate awareness of deficits on
the individual’s part in order to be effective
Cognitive Remediation
Cognitive remediation or rehabilitation at
any level (acute or community re-entry) is
the teaching of compensating strategies to
either develop or augment skills that the
individual needs to experience an
independent meaningful life.
Cognitive Remediation
 Cognitive Rehabilitation is all about
- Gives the person the skills and choices to
develop control in their life!
- Important to develop this control in the
shortest amount of time possible
 Use of cognitive strategies is a LIFE LONG
Cognitive Remediation
Competency equals the development of
appropriate cognitive strategies
Part of the task of Cognitive Rehabilitation is
developing a “New Normal” and leading that
person towards acceptance. This involves
attention to both cognitive issues and
emotional/ psychiatric issues
Development of Compensatory Strategies
Adjustment to the use of these strategies
requires family involvement and a change in
the families expectation and messages that
it send to the individual
Compensatory strategies are specific to a
task, place or function
Important Items To Keep In Mind
Compensatory strategies typically
involves one or more of the following:
1. Change in the task
2. Change in the environment
3. Change in how the person performs
the task
4. Use of some type of prosthetic
Determining What Areas to Focus On
Assess and identify the individual’s deficit areas
with regard to cognitive, behavioral, social and
language dysfunction
Determine the individual’s strengths and
Inventory individual’s perceptions as to which
areas are causing them the greatest personal
Determining What Areas to Focus On
Talk to supportive personnel (family, friends,
staff), obtain their input on areas the individual
struggles with
Prioritize those deficit areas that are having a
GLOBAL affect on the person’s daily lifestyle
Establish goals for the most fundamental skill
Recommendations toward the Successful
Training/Utilization of Compensatory Strategies
Engage the individual in strategy selection
Chose goals that are concrete and functional in
Use tasks relevant to the persons life to
remediate functions. Use real life tasks that are
relevant to the person
Recommendations toward the Successful
Training/Utilization of Compensatory Strategies
Consider the individual’s personal history,
personality, premorbid status and current level
of functioning. If the strategy is too difficult,
culturally inappropriate, demeaning etc. you
are doomed to failure
Be creative and flexible
Recommendations toward the Successful
Training/Utilization of Compensatory Strategies
Make learning the strategy fun, personal and
thereby motivating. Incorporate, when possible,
the person’s interests
Translate what the individual should do into what
they want to do
Look at each client as an individual. Don’t mass
produce strategies and expect them to fit every
Recommendations toward the Successful
Training/Utilization of Compensatory Strategies
Initially, allow the person to fail before
 When intervening provide the least
assistance possible to identify where the
task brakes down
Recommendations toward the Successful
Training/Utilization of Compensatory Strategies
As the person is performing the task, ask what
they are thinking
 Do they know there is a problem and what it
 Do they know what to do next but can’t
figure out how?
Factors Effecting an Individual’s Ability to
Utilize Cognitive Strategies
Level of awareness
 Level of acceptance
 Emotional status
 Level of motivation
 Family/ social support
Components of Attention
 Sustained Attention/ Concentration
 Working Memory
 Selective Attention
 Alternating Attention
 Divided Attention
Primary Treatment Strategies
 Pacing:
Regulate the amount of energy the person
expends doing a task. Avoid fatigue
Schedule tasks requiring attention at time
when the individual has the most energy
Schedule rest periods and breaks
Primary Treatment Strategies
Regulate the flow/ speed of information
Regulate the amount of information
Reduce sources of stimulation/ distractions
Talk out loud to self/ verbal labels
Write down brief list of what to attend
Primary Treatment Strategies
Do one thing at a time. Ask people to
wait until you finish what you are
Increase variety
Allow a realistic time frame for
completion of task
Visual or auditory cues
Primary Treatment Strategies
Change the task. Break down tasks into
components. Do each component
Audio tape lectures etc.
Formal Attention Training
Components of Memory
Explicit (declarative) vs. Implicit
(Procedural) Memory
Encoding, Storage (Consolidation),
Retrieval Processes
Old (Remote) vs. Recent Memories
Auditory vs. Visual Modalities
Primary Treatment Strategies Memory
 Maximize (train) attention
 Reduce environmental distractions
 Downgrade memory demands
- Amount of material to be remembered
- Periods of delay between presentation of
info. and recall
- Simplify information
Primary Treatment Strategies Memory
Organize/ Categorize information
Translate into your own words
Relate something new to something familiar
Break down info into small pieces
Multi-sensory input
Provide opportunity for repetition. Rehearse
during the first hour after the event
Primary Treatment Strategies Memory
Practice output
Provide verbal reminders/ written prompts
Develop a set routine/ procedure
A picture is worth a thousand words
Develop a memory organizer
Use Lo-Tech Devices: Beeper, watches,
Chart progress
Word Mnemonic – Each letter cues
recall of an idea Social Pragmatics
(L)ook at the person
(I)nterest yourself in the conversation
(S)peak less then ½ the time
(T)ry not to interrupt or change the topic
(E)valuate what is said
(N)otice body language
 Sentence Mnemonic – First letter of
each word cues a specific memory or
sequence of idea
(A)ll (G)ood (B)oys (D)eserve (F)avor
 Rhymes – Sing song reminder
I before E except after C. Not for
sounds like “AHY” as in neighbor or
Memory Organizer System
 Purpose: Make ones life easier, less
stressful. Promotes success and acts as a
safety net.
 Who needs it: people with
1. Memory problems
2. Difficulty with organization
Memory Organizer System
Form: varies dependent upon sensory,
physical, cognitive and emotional
Need to take into account personal
preferences and lifestyles
Commercially available or home
made.Electronic or paper.
Memory Organizer System
Prospective memory: to do list
Phone numbers/ addresses
Calendar appointment
Log of daily events
Project or task information
Graphs or tables of accomplishments
Lists of strategies to use
Memory Organizer System
 Steps for carrying out routine/ frequent tasks
 Steps for carrying out infrequent tasks
 Plan of how blocks of time are to be allocated to
tasks during the week.
 Overview of how to approach a problem/ decision
 Flow diagram of things/ steps to do in a project
Memory Organizer System
Personal style & Comfort (e.g.
professional look vs. school notebook)
Lose-leaf (with indexed sections)
Presentation (2 pgs. = 1 wk., 1 day or
2 days)
Shop before buying
Memory Organizer System
List - To do lists
Table - 1 or 2 daily routine activities (i.e.
Outline - Organizing simple tasks only
Boxes & Flow Diagrams - Organize
sequences or steps of complex tasks.
Good for problem solving situations which
require decision making
Memory Organizer System
Combining Lists & Box-Flow Diagrams
 Remembering appointments
 Organizing one’s time
Memory Organizer System
 Implementing a Memory Organizer
-Only one system
-Set up Section(s): at least List and
-Learn how to use organizer
training: rote learning, role playing
-Remembering to remember: regular time
& review times
-Locating memory organizer: routine place
-Revise/ update system as needs change
Components of Executive Functions
Problem Identification/ Preparation
 Goal Formulation/ Hypothesis Generation
 Planning
 Organization
 Initiation
 Self-Regulation/ Self-Monitoring
(sequencing, error recognition and
correction, follow-through
Primary Treatment Strategies:
Executive Functions
Maximize (train) attention
Choose less complex versions of the activity
Break down task into components
Simplify task. Condense or eliminate non-vital
steps. Reintroduce once learned.
Provide clear, simple instructions that impart
a structure for the performance of the task
Primary Treatment Strategies:
Executive Functions
 Organize/ planning
Use flow diagrams or outline
 Initiation
-Educate the individual and family as to the nature
of the problem
-Develop schedules.
-Forward and backward chaining
-Lo-tech devices (beepers, watches)
 Role Play
Executive Functions: Problem
Solving/ Decision Making
Problem Solving
SOLVE Mnemonic
(S)pecify the problem – Define it
(O)ptions – What are they?
(L)isten to other’s opinions and advice
(V)alue Clarification – Is the problem worth
(E)valuate and Recycle – Was the problem
 Many
types of challenging behaviors can
result from TBI
 Different types of problems require different
types of interventions
 Driven by the needs/wants of the individual
AND their capabilities
 Creative thinking, knowing and listening to the
person, and being willing to modify strategies
lead to greatest successes
 Not
every strategy will work in every
 Be a diligent observer (ABCs)
 Plans/interventions will need to be
modified over time
 These things can really work, and can
really help increase quality of life!