Slide 1

Report
Practical Strategies for Managing
Executive Function Impairments
in Students with TBI
McKay Moore Sohlberg, PhD, CCC-SLP
Bryan Ness, M.S., CCC-SLP
University of Oregon
Communication Disorders & Sciences Dept
Outline
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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
necessary for formulating
goals, planning how to achieve
them, and carrying out the
plans effectively” (Lezak, 1982)
Executive Functions:
Functional Definition
(Feeney, 2005)
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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
One More Definition…
(Sohlberg & Mateer 2002)
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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)
(Feeney, 2005)
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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
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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
DES and Brain injury
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Traumatic brain injury (TBI)
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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
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Attention Deficit and Hyperactivity
Disorder (ADHD)
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Autism
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Impaired response control and sustained
attention
Impaired task switching (i.e. perseveration)
Learning Disability
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Working memory deficits and reduced
strategy use.
Examples of classroom impact
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Assignment management
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In-class behavior regulation
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Difficulty staying “on task”
Struggle to transition from one activity to
another
Mathematics
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Unable to recall assignments
Difficulty gathering/organizing materials
Difficulty starting and remaining engaged in
work
Difficulty sequencing multi-step procedures
Reduced performance monitoring
Writing
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Difficulty planning a narrative
Common misperceptions
The child with DES…
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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
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Effects of brain injury in children are
particularly profound because the
injury occurs to a developing brain
(Welsh & Pennington, 1988)
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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
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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
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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
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High Tech/Multipurpose
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PDA
Computer
Time Management
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Timex Data Link Watch
Kitchen timers
Day planner
Example of External Aid (cont)
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Task Specific
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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
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Self-monitoring of Attention
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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
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Self-monitoring of Performance
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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 and
motivation on checklist
Student self rates success
during and after task and
documents successful strategies
Examples of Metacognitive Strategies
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Self-talk/Self-regulation
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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
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Seating
Desk Barriers (ear plugs/head set)
Desk set up (no irrelevant items)
Paper handling systems
Environmental ModificationTask Accommodation
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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
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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
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External aid + metacognitive
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Natural supports + external aid
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Digital timer and self-talk routine
Classroom/school wide culture and
assignment completion systems
Environmental modification +
metacognitive
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Task accommodation and ask for help
For any strategy, think about…
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Selection
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Training
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TEACH-M model
Measuring impact
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The child’s personal preference
Cost
Ease of use
What is the target?
Homework completion, writing skills, on-task…
Supporting Use
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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.
The Plan B Approach:
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 experimentation
Plan A - Plan B - Plan C
Testing time line)
OCHTA
(modified from Yvilsaker & Feeney)
1.
2.
Observe in…
Context
3. Hypotheses generation
4. Test hypotheses
5. Assess outcomes; modify program
Example:
Step
Comments
Observedefine
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
Test
hypothesis
Develop homework survey for parent &
teacher to determine breakdown--find
out it is a tracking problem
Implement
Intervention
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
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Practice applying OCHTA to EF
interventions.

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