1. Strategies & Interventions
Brain Injury and Executive Functioning
Rachel Toplis, PhD
Dr. Jonelle Neighbor
Refer to earlier presentations.

2. 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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3. 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!

4. 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.

5. 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)

6. Examples of Functional Executive Skills
Attention and Concentration
New Learning
Mental Processing
Emotional Control
Reasoning and Problem Solving
Organizational Skills
Memory
Initiation
Functional executive skills. In the literature others are identified such as persistence, impulsiveness, time management etc.

7. 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

8. What disabilities are impacted by dysexecutive functioning?
Traumatic Brain Injury
Specific Learning Disability
Attention Deficit / Hyperactivity Disorder
Autism
Tourette’s Syndrome
Schizophrenia
Depression
Obsessive Compulsive Disorder
Dementia
Etc…..

9. Development of Executive Functioning

10. Attention and Self Control
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

11. 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
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

12. 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

13. 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

14. 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

15. Strategies and Interventions for specific areas
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.

16. Behavioral Definitions & Expression of Dysfunction
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.

17. 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.

18. 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.

19. 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.

20. Organization – Establishing or maintaining order in an activity or place; carrying out a task in a systematic manner.
Self Monitoring – Checking one’s own actions during, or shortly after finishing the task / activity to assure appropriate attainment of goal.
Scattered, disorganized approach to solving a problem, easily overwhelmed by large tasks or assignments.
Does not check for mistakes, unaware of her own behavior and its impact on others.

21. 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.
Stop and think methods – classroom and small group curriculums. Don’t react – look and listen, express feelings, consider consequences, think of solutions.

22. Inhibit Student Based Peer role models, cross age tutoring.
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

23. 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.
Cue cards – E.g., Does a word have multiple meanings? Is a word both a noun and a verb? Does this passage have inferences, metaphors, or expressions

24. 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).

25. 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.
Inhibition options = Promote active planning, goal setting, and selection of best-bet strategies.

26. 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.

27. Initiate External Structure May need external cue to get started.
Increase structure in the environment.
Use routines or steps of a task as a prompt.
May need external cue to get started.

28. 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.

29. Working Memory External Structure
Pre-teach framework for new information and guide attention to important parts.
Rate of presentation may need to be altered.
Information broken down into smaller chunks.
Rehearse and review new information frequently.
New information should be concrete and memorable.
Printed list of daily activities, locations, and materials needed.
10 – 15 more repetitions than student without working memory deficit.
Active listening – attending (eye contact, posture – facing speaker), paraphrase, clarify / perception check, summarize.
Visual imagery is a flow of thoughts you can see, hear, feel, smell, or taste. 

30. Working Memory Student Based Visual Imagery.
Practice, practice, practice.
Encourage verbal rehearsal/self-talk.
Write a checklist of steps.
Learn ‘active listening’ techniques.
Visual Imagery.
Teach to chunk information.
Use rehearsal, repetition and paraphrase.
Provide study outlines

31. Planning ExternalStructure “Cookbook” of steps.
Provide examples of how students might plan differently to reach the same goal.
Overtly teach goal setting
“Cookbook” of steps.
Adult modeling.
Scripts
SQ3R. Survey – look through assignment, headings, pictures etc. Question – turn headings into questions. Read – to find answers, identify main idea etc. Recite – state the gist of what was read. Review – Check recall of important information.

32. Planning Student Based Provide outline of lesson.
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.

33. 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.

34. 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”.
Math Script – long division, problem because numbers misaligned, use graph paper.
Beh script – not completing work, run out of time, use visual timer.

35. Organization External Structure Cornell notes or two column notes
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

36. Organization Student Based Folders and planners
May need help from adult to organize materials.
‘Organization time’ at the beginning and / or end of the day.
Folders and planners
Writing checklists.

37. 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

38. 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

39. 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?

40. 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?

41. 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?

42. 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.

43. 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.

44. 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.

45. Attention and Focus
Self monitoring tasks.
Getting students attention.
Auditory signals (ring bell, clap pattern, verbal signal ‘freeze’).
Self monitoring tasks – group or individual. Set timer, Check on task / off task. Review, problem solve, try again see if can improve score.

46. Attention and Focus Use partial outlined study guides / sheets.
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.

47. Attention and Focus Limit Noise Remove distractions
Provide concrete visual cues
Limit amount of info on a page.
Adjust assignments.
Focus on most salient aspect of lesson.
Maintain brisk pace.
Repeat instructions

48. Attention and Focus Use short and concise instructions.
Reinforce on-task behavior.
Give frequent breaks.
Break assignments up.
Set up personalized cuing system based in classroom system(s)
Personalized cuing system – 1) timer on desk – next 10 minutes beat the clock. 2) break large assignments into smaller chunks, end of each small chunk reflect whether on task or not.

49. Great Resource www.cokidswithbraininjury.com
Pull up matrix and review MEMORY VISUALSPATIAL ORGANIZATION

50. 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.

51. LearNet: www.bianys.org/learnet
REAP concussion management plan (Reduce-Educate-Accommodate-Pace).
Cokidswithbraininjury.com
Offers the newest information on brain injury and best practices for working with a child with BI in school.
LearNet:
Resources for providing interventions and accommodations for a child with a brain injury.

52. Resources for Presentation
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.