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
Tolerance
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
unexpected
Ways to Deal with
Challenging Behaviors
Medications
Behavioral
Cognitive
Programs
Remediation
Strategies
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)
1.
2.
3.
4.
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
precision).
Must be analytic (i.e., convincing evidence that
the intervention is responsible for the change in
behavior).
Must be technological (i.e., techniques could be
duplicated by another).
Seven Essential Elements of an
ABA-based Program
5.
6.
7.
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
behaviors).
Six Steps for a Solid
Applied Behavioral Analysis
1.
2.
3.
4.
5.
6.
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
act
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
appropriately
Once the Target Behavior is
Identified…….
We
need to learn all we can about this
behavior
Is it a behavior we want to increase?
Is it a behavior we want to replace?
– Inadequate in meeting an individual’s
needs?
– Inappropriate in the current environment?
Behavior “Modification”
Modification
of behavior is most effective if
the motivation behind the behavior can be
determined
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
consequences
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
behavior
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
depressed)
Motivations/Purposes of
Challenging Behaviors
To
escape from or avoid an undesirable
situation
– Often in anticipation of a request to work, go to
an activity, communicate, be in an environment
they find uncomfortable, loud, overstimulating,
etc.
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
CONSISTENCY
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
instruction/cue
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:
Guidelines
Make
sure you have the individual’s attention
Instructions should be simple and clear;
concisely communicate only the most salient
information
Be consistent in beginning stages; can be varied
in many settings to encourage flexibility and
generalizability as response occurs more
regularly
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
future
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
environment
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
reinforcer)
– 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
behavior
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
discouraged)
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
Consequences
for correct and incorrect responses/
behaviors should be easily distinguishable
If
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
period
Token Economies
Provides
a TANGIBLE marker of
progress
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
behavior
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
shift.
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
opportunities
– 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
occasions.
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
present?
– 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
STRATEGIES FOR HELPING
INDIVDUALS WITH
COGNITVE IMPAIRMENTS
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….
Neuropsychological
testing = IQ
Neuropsychological
testing =
Academic testing
Neuropsychological
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
medication/treatment
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
environment?
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
success?
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
Tolerance/Effort
Level of distractibility/ability to follow directions
Fatigue/Endurance
Affective Status
Physical
Cognitive Domains Assessed
During Neuropsychological Evaluation
Attention
Memory
Somatosensory
perception
Visual-spatial functioning
Language
Executive function
Mood
Interpretation/Summary of Results
Quantitative
Data
– Appropriate Norms
– Consideration of an individual’s own baseline
Qualitative
Data
– 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
Influenced
by factors such as:
–Type (penetrating or closed, focal or
diffuse)
–Severity of injury
–Site of injury
–Length of time since injury
–Age
–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
Functions”
– 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
vulnerable.
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.
SKILLS-TRAINING MODEL
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
SKILLS-TRAINING MODEL
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
STRATEGY SUBSTITUTION
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
STRATEGY SUBSTITUTION
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
CONTROL.
- 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
commitment!
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
device
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
weaknesses
Inventory individual’s perceptions as to which
areas are causing them the greatest personal
distress
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
first
Recommendations toward the Successful
Training/Utilization of Compensatory Strategies
Engage the individual in strategy selection
Chose goals that are concrete and functional in
nature
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
client
Recommendations toward the Successful
Training/Utilization of Compensatory Strategies
Initially, allow the person to fail before
intervening
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
is?
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
Arousal
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
doing.
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
independently.
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,
reorders
Chart progress
MEMORY STRATEGIES
VERBAL MNEMONICS
Word Mnemonic – Each letter cues
recall of an idea Social Pragmatics
(LISTEN)
(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
MEMORY STRATEGIES
VERBAL MNEMONICS
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
weigh
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
limitations.
Need to take into account personal
preferences and lifestyles
Commercially available or home
made.Electronic or paper.
Memory Organizer System
MEMORY/CONTENT
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
ORGANIZATION/CONTENT
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
FEATURES
Personal style & Comfort (e.g.
professional look vs. school notebook)
Lose-leaf (with indexed sections)
Size
Presentation (2 pgs. = 1 wk., 1 day or
2 days)
Shop before buying
Memory Organizer System
FORMAT
List - To do lists
Table - 1 or 2 daily routine activities (i.e.
meds)
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
Schedule
Remembering appointments
Organizing one’s time
Memory Organizer System
Implementing a Memory Organizer
-Only one system
-Set up Section(s): at least List and
Calendar
-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
-Consistency
-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
solving?
(E)valuate and Recycle – Was the problem
solved?
Summary
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
Summary
Not
every strategy will work in every
situation
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!