1. Helping Me to Help Myself: A Common Sense Approach to Self- Regulation Intervention Tim Feeney, Ph.D. Executive Director School and Community Support, Inc. Project Director New York State Neurobehavioral Resource Project 17 British American Blvd Latham, NY 12110 tim@positivesupport.org 518-782-7100

2. www.positivesupport.org

3. What’s the Plan?  Me: Communicate respect and recognition that there are a lot of people in this room who know a lot more than me.  Me: Remember! There are a lot of people who are already doing the stuff that I’m going to talk about.  Me: Provide you with some practical approaches to supporting individuals in the development of self-regulation;  Me: Answer your questions and help you with real situations that you provide.

4.  You: Slow me down if I’m talking too fast.  You: Put your cell phones on buzz. Please.  You: Think about how you can apply this stuff in your lives and your work.  You: Make plans for creating and participating in the development of this stuff in your places.  You: Ask questions! Your Jobs

5. More Grandma Masse “Models collect dust on shelves.” Don’t fall in love with a particular approach – ideally, you’ll/we’ll create a framework for intervention (a working theory) that will evolve with experience and evidence

6. Grandma Masse’s Rules for Success: “The smart guys are the guys who learn from the other guys. Don’t get all caught up in one thing; everyone believes their thing is the best thing and they’re usually wrong. So, shut-up and listen and learn and change.” In order to be successful you’ve got to be eclectic.

7. Common Questions  How much of this is brain injury anyway?  How many angels can dance on the head of a pin?  It’s impossible to know.  The issues confronting the individual with brain injury are a combination of environmental factors, pre-injury history, the site of injury, and the severity of injury.

8. Common Questions  When should s/he return to school?  As soon as possible.  There is evidence that the longer the period between discharge from rehab and entry into school to worse the outcome (in both the short and long term).  There is great benefit to articulate the needed supports and a plan to reduce those support as part of any transition plan.

9. Common Questions  When do we get a neuropsychological evaluation?  When you are looking to make someone eligible for services  There is ample evidence that most neuropsychological evaluations are notoriously poor predictors of individual performance in context – they have very limited ecological validity.

10. Common Questions  Is there a standard for therapy?  No! (Although, there is increasing evidence that when interventions are done in context, there is a better change of sustained change and, many approaches that are used with other populations are also effective with individuals with BI)  There is little evidence supporting the use of much of what is used in, and recommended by, rehabilitation professionals.  Cognitive therapy – no evidence of generalization of skills learned in decontextualized training formats.  Office-bound or specialized settings – no evidence of generalization  Social skills training – no evidence

11. Common Questions  What about medications?  There is some evidence that stimulants have some positive effect in increasing individual gains early in rehabilitation (and amantadine).  Otherwise, nope. Remember most psychoactive medications are prescribed either hypothetically or symptomatically; and this is not necessarily a bad thing.

12. Brain Injury is an event not a disability  The disabilities that result from brain injury are a primarily function of the severity of the injury, the age of the individual at the time of the injury, and the site of the injury (amongst other things).  In addition, the individual’s history pre- and post-injury will affect long term outcomes.  Finally, the disabilities associated with brain injury tend to be contextual; that is, different issues arise is different contexts.

13. While there are common traits, everyone’s brain injury manifests itself differently, so any intervention strategies will need to be tailored to address these differences. Chuck’s brain injury is different than Connor’s brain injury is different than Sarah’s brain injury is different than Devan’s brain injury

14. “Brain injury makes me me, only more.” - Jason Lewin

15. BRAIN INJURY Congenital Brain Injury ▪ Cerebral Palsy ▪ Autism ▪ Mental Retardation Acquired Brain Injury General Issues ▪ Scatter based on recovered knowledge/skill vs. new deficits knowledge/skill vs. new deficits ▪ Assessment challenges ▪ Neurological change and recovery often leading to delays in disabilities often leading to delays in disabilities ▪ Loss/emotional adjustment ▪ Family challenges/grieving Traumatic Brain Injury Closed Head Injury Open Head Injury ▪ Profile varies with the site of injury ▪ Frontal Lobe Injury/Executive Function Impairments ▪ Reduced ability to plan and set goals ▪ Reduced ability to plan and set goals ▪ Reduced ability to self-monitor –initiate – inhibit ▪ Reduced ability to self-monitor –initiate – inhibit ▪ Reduced problem solving and flexibility ▪ Reduced problem solving and flexibility ▪ Reduced ability to transfer and generalize learning ▪ Reduced ability to transfer and generalize learning ▪ Reduced abstract reasoning ▪ Reduced abstract reasoning ▪ Temporal Lobe Injury ▪ Reduced memory ▪ Reduced memory ▪ Reduced learning efficiency ▪ Reduced learning efficiency ▪ Reduced emotional control ▪ Reduced emotional control ▪ Diffuse Axonal Injury ▪ Reduced info proc efficiency ▪ Reduced info proc efficiency ▪ Reduced stamina ▪ Reduced stamina ▪ Stroke/CVA ▪ Tumor ▪ Anoxia ▪ Encephalopathy

16. Applied Behavior Analytic Approaches Baer, Wolf, Risley, 1987; Kantor, 1959; Skinner, 1953; Tharp & Wetzel, 1963 Setting Events & Establishing Operations Fox & Conroy, 1995; Michael, 1982;1993 Daily Routines/ Picture Routines Bondy, 1995 ; Koegel & Koegel, 1997; Wetzel & Hoschouer, 1984 Positive Behavior Supports Carr et al, 2002; Horner et al., 1990 Communication-BasedIntervention Carr et al., 1996; Durand, 1990; Reichle & Wacker, 1993 Socially Co-constructed Narratives Hudson & Fivush, 1993 Functional Behavior Assessment Carr & Durand, 1995; Iwata et al., 1994 Dynamic Assessment Feurerstein, 1979 Apprenticeship in Thinking Rogoff, 1990 Socially Mediated Cognitive Approaches Vygotsky, 1932; 1987 Planning Friedman & Scholnick, 1998 PERSON-CENTERED,CONTEXT-SENSITIVE,SELF-REGULATORYINTERVENTION Generalization & Maintenance Carr et al., 1990; Dunlap, 1996 Self-Regulation & Belongingness Baumeister & Vohs, 2003; Mischel, 2001 Self-Determination/ Motivation Theories Deci & Ryan, 2002 Situated Cognition Greeno, 2004 AnEvidence-Based,Integrated Approach to Intervention

17. So, why is self-regulation so important?

19. Aggression

20. Impulsive Behavior

21. Socially Awkward Behavior

22. Impaired Judgment

23. Generally Impaired Self-Regulation

24. Delayed Gratification!!

25. Self-Regulation and supporting individuals in the development of self-regulatory behaviors cannot be implemented as stand-alone or an independent “curriculum” separate from academics; self-regulation supports academics, is integral to academic success, and is foundational to effective teaching and learning.

26. SocialCompetence Self-Regulation of Behavior Academic & VocationalGrowth A Conceptual Shift: From “Teaching Skills” or “Increasing Knowledge” to Developing Competence in the Use of Skills and Knowledge

27. The Point: Self-regulation and academic achievement are inseparable Managing my attention increases my academic success Managing my emotional state improves my ability to do the hard stuff Being organized (cognitively) helps me to remember what I’m learning Working together positively improves my overall performance

29. Three Beliefs That Will Affect the Likelihood That You’ll Be Successful  Optimism & Hope. Evident in the problems that are targeted and the language that is used when describing the individual and when interacting with the individual.  Appreciating the Influences of Contextual Factors on Behavior. Requiring an understanding of the setting events (the distant events on an individual’s behavior).  Applied Pragmatism. Recognizing that there is no single “right” solution; moving away from the notion of “consistent” use of a prescribed intervention strategy to “concordance” on the part of all involved.

30. You can make people do things that they just don’t want to do but the price for doing so will be high

32. Being good at self-regulation requires movement from irrational exuberance and irrational negative attribution. All the while keeping your sense of humor.

34. Successful intervention is about establishing a respectful relationship with someone who’s doing his or her best to tick you off

35. Poodl e

36. Most of the success that you will have will be direct result of the quality of the relationship that you have with the kids in your classroom The best conceived approaches will FAIL if there is a poor relationship between the adults and kids. This does not mean you all have to jump off a bridge together.

38. It’s important to have fun with and create opportunities for fun and to laugh a lot even in the face of significant challenges

39. Let’s play hide and go f**k yourself! Let’s play hide and go f**k yourself!

40. The glass ain’t half empty, it’s half full! and You can teach 1/2 empty people to become 1/2 full people (it’s hard to teach 1/2 empties to become 1/2 full)

42. Introduction to Intervention Ideas: Conceptually Simple, Procedurally Difficult

43. This is Hard Stuff to Do! There is No Magic Bullet; No Simple Solution

44. Introduction to Intervention Ideas: Conceptually Simple, Procedurally Difficult

45. Culture and Community  Values and meaning  Membership  Roles and responsibilities  Relationships H & F

46. The Importance of Community in Establishing an Identity  Communities help us to accomplish things.  Communities are change agents.  Communities are sources of meaning and belonging.  Need to Belong (Baumeister & Leary, 1995)  “The need to belong is a powerful, fundamental, and extremely pervasive motivation.”  A lack of belongingness constitutes severe deprivation and causes a variety of ill effects. “Alone.... Uh, I’m alone! I'm a lonely, insignificant speck on a has-been planet orbited by a cold, indifferent sun. “ -Homer Simpson  The Belongingness Hypothesis: A drive to form and maintain at least a minimum number of lasting, positive, and significant interpersonal relationships.

47. Social Identity Theory  People have an innate and strong tendency to mentally organize things and people into categories  To the extent that we associate ourselves with communities (i.e. categorize ourselves), we have social identities  Social identities (via our community memberships) are important aspects of how we define ourselves  To the extent that we identify with communities that are valued (e.g., powerful, prestigious, high status, popular), we’ll feel good about ourselves.

48. A Community Shared purpose Recognition of individual needs Ongoing articulation of purpose Identity(ies)/Roles/Places/Jobs Procedures for managing situations when participants are out of roles Shared Projects Procedures for feedback from community members Community Meetings Staff Roles – Leader, supporter Participant Roles – Leader, supporter, facilitator

49. Common Sense Examples of Approaches to Establishing a Community  Rituals of Greeting/Checking In  Entering School  Entering the Classroom  Rituals of Leaving/Checking Out  Leaving the Classroom  Community Meetings: What are we about? How are we going to live together?

50. GOAL OF INTERVENTION  The individual not only behaves in ways that are acceptable, but CHOOSES to behave in ways that are acceptable  Thus cognitive and executive self- regulatory functions are inevitably part of behavioral interventions  The intervention is accomplished with as little failure as possible

51. For behavior-outcome linkages to serve as motivators, people must understand them, see them as relevant to their lives, and have the capabilities for utilizing them. - Edward Deci, 1995 Why We Do What We Do In other words: People need to have both the strategies and capacities for attaining desired outcomes!

52. An impulse is not a choice

53. When choice is offered, of course, it is essential that the person being offered the choice have the information necessary for making a meaningful decision... without such information, being given a choice will feel more like a burden than a support for autonomy. - Edward Deci, 1995 Why We Do What We Do

54. Choice (Noun) 1 The act of choosing; selection 2 the right, power, or chance to choose; option 3 a person or thing chosen 4 the best or most preferable part 5 a variety from which to choose 6 a supply that is well chosen 7 an alternative 8 purposive discernment.

55. Impulse (Noun) 1 a) an impelling or driving forward with sudden force b) an impelling force; sudden, driving force; push; thrust; impetus 2 a) incitement to action arising from a state of mind or external stimulus b) a sudden inclination to act, usually without premeditation 3 sudden involuntary inclination prompting action.

56. Functional Conceptions of Choice: Free choiceFree choice Fixed choiceFixed choice Forced choiceForced choice Feeling the natural and logical results ofFeeling the natural and logical results of actions in the environment

57. So, what are you doing? Why are you doing that? How’s it going? Is this helping? Not Helping? What are you hoping to achieve? What else can you do? What’s your plan? Some Scripts That Will Help You Figure Out if This is Really A Choice

58. “Intelligence is not just a gift- it’s a choice” -George Shaffner The Arithmetic of Life Success results from using what you’ve got - not from what you’ve got!

59. Context Relevancy: How does this stuff apply to the bigger world? adapted from Sailor, 1999 Useful: Useful: Do the outcomes that we’re targeting produce something useful to the individual in long run? Desirable:Desirable: Does the individual choose the outcomes for him/herself when given the choice? Is the individual given thechoice of outcome? Social: Social: Do the outcomes result in behaviors that will increase interactions with persons other than paid staff? Practical:Practical: Will the behavior be used in real contexts without staff support? Adaptable:Adaptable: Is there a focus on developing skills that can/will be used in a number of situations and without staff?

60. UNIFORMITY is not necessarily a good quality in intervention There is no single “right” solution - sometimes the best you can do is keep trying Plan A Plan B Plan C Sometimes what works today won’t work tomorrow!

61. Most of the stuff that works is conceptually simple but procedurally difficult. In many ways good intervention is really about the systematic application of common-sense. Unfortunately, “common-sense is terribly uncommon.” – Mark Twain

62. Introduction to Intervention Ideas: Conceptually Simple, Procedurally Difficult

63. Common Themes of All Successful Interventions Intervention must be delivered early andIntervention must be delivered early and intensively, through established routines, and focus on the development of self-regulation and problem-solving strategies in context. In absence of meaningful engagement in chosen In absence of meaningful engagement in chosen life activities all interventions will ultimately fail. Long term, flexible, and frequently adjustedLong term, flexible, and frequently adjusted supports may be needed to prevent behavior problems and to facilitate social development.

64. Self-Regulation: Intervention Range of options: highly confrontational to non- confrontational. The degree of confrontation that is appropriate depends on:  length of time post injury  seriousness of the consequences of unawareness  severity of anosagnosia/potential for change  emotional fragility  age/maturity  available resources and support  environment

65. Cognition Communication Behavior

66. BEHAVIOR Excesses Impulsiveness Aggressiveness Substance Abuse Deficits Initiation Impairments Insight Impairments COMMUNICATION Efficiency Fluency/Articulation Discourse Effectiveness Functional Apparent COGNITION OrganizationMemoryInfo Processing PlanningProcedural vs. DeclarativeNon-strategic Self MonitoringImplicit vs. Explicit Reviewing Self-evaluating

67. Why Do I Keep Making the Same Mistakes? Why doesn’t it Get Better?

69. Success via Learning from Consequences ConsequencesPresupposes: Reasonable intactness of the neural networks responsible for connecting: Memory for the factual aspects of past behavior and/or Memory for the “Somatic Markers”, or the feeling states associated with the consequences of those behaviors Without these connections in memory, past rewards and punishments lack the power to drive future behavior

70. Why am I getting up in the morning? MEANING

71.  Know that an event or activity will be difficult  Establish reasonable goals (in some cases these might be immediate)  Formulate a plan to achieve the goal (or understand the plan)  Initiate goal-directed behavior  Refrain from actions that interfere with the successful achievement of goals  Attend to and evaluate how well they are doing  Try another plan or strategy if things are not going well To Assure Long Term Success Individuals Need to:

72. Themes SELF REGULATION DEVELOPMENT Themes  Start early  Develop slowly  Continue into adulthood  Influenced by biologic and environmental factors  Variability: Context (person, setting and task), motivation, culture

73. SELF-REGULATORY DEVELOPMENT: The Role of Experience Individuals are more likely to develop effective self- regulation if they:  Experience adequate social attachment  Experience an organized and predictable world  Receive “authoritative/apprenticeship” parenting, including effective modeling and verbal mediation  Are rewarded for appropriate self-regulation and control by others who value self-regulation and autonomy

74.  Think out loud.  Think out loud a lot.  Think out loud with the person: reflect, plan, problem solve, observe, organize, evaluate, remember, review, create, etc.  Make use of external supports when thinking: diagrams, photos, written routines, day planners, notes, etc.  Present yourself as an image of thoughtfulness. Help the individual to embrace the notion that being thoughtful is a good and great thing.  Think out loud in a way that shows that you are fun and flexible and experimental in your own thoughts.  Think out loud in a way that captures metaphors, analogies, similarities, history, etc. Teaching a Learning How to Think

75. The Three Big Things

76. “When we think of your future – the next 10 years – we need to think about the 3 most important we need to think about the 3 most important things to work on; the things that, if you achieve, you’ll have a meaningful life.” The 3 Things tend to cluster around these areas: Behavioral regulation/self-regulationBehavioral regulation/self-regulation Friendships/social-interactionFriendships/social-interaction Vocational skills/meaningful engagementVocational skills/meaningful engagement Self-help skillsSelf-help skills

77. Being intrinsically motivated has to do with being wholly involved in the activity itself and not with reaching a goal. -Edward Deci, 1995 Why We Do What We Do

78. Making the “Big Things” Real  Creating personal maps or steps to attaining the personally meaningful goals.  Articulated by the individual (with some help from staff, friends, family)  Organized in a visual manner to assure clarity

79. Step 1. Me Now I’m good at: I need to: Step 55. Me the: _______ I’m good at: I need to: Step 2. Step 3.

80. KEEPING A HOTTIE BOYFRIEND IN THE RESOURCE ROOM DEALING WITH PROBLEMS /BEING IN CONTROL LISTENING TO GOOD ADVICE/IGNORING BAD HANDLING MYSELF IN CLASSES HANDLING MYSELF OUT OF CLASSES BEING A GOOD PERSON WITHOUT THINKING ABOUT IT EULA’S STEPS TO SUCCESS

81. HAVING A JOB, LIVING IN MY APARTMENT IN A TREATMENT PROGRAM MAKING MEETINGS & PARTICIPATING IN THEM MAKING MY PLAN TO STAY CLEAN EVERYDAY & LETTING PEOPLE KNOW DEALING WITH ASSHOLES POSITIVELY MAKING PLANS BEFORE GOING OUT IN THE WORLD GET OUT OF IT BEFORE I GET INTO IT PETER’S STEPS TO SUCCESS FOLLOW MY PLAN WHEN I’M OUT IN THE WORLD People, Places, Things DON’T FORCE IT

82. In rehab A doctor An EMT Be a helping person Tom’s Plan & Tom’s Reality

83. More Intervention Ideas: Conceptually Simple, Procedurally Difficult

84. PERSON Mental Health Cognition LanguageEmotionVolitionBehavior Human beings are a collection of relatively independent structures, processes, and systems

85. John’s Cognition AttentionPerceptionMemoryOrganizationReasoningEF Arousal Select Direct/ Filter Maintain Divide Shift Encode/Store/Retrieve Episodic/Semantic Explicit/Implicit Declarative/Procedural Involuntary/Strategic Working Memory/ Knowledge Base Remote/Recent Pro/retrospective Iconic Sequence Categorize Associate Analyze Synthesize Inductive Deductive Analogical Divergent Convergent Goals for John - John will: 1.Increase duration of maintained attention 2.Increase prospective memory from 3 to 5 minutes 3.Increase category naming from 3 to 5 members per category

86. John’s Mental Health Axis IAxis IIIAxis IIAxis IVAxis V Personality Disorders Mental Retardation General Medical Conditions Global Assessment of Functioning Goals for John: John will 1.Participate in psychotherapy sessions without falling asleep 2.Comply with his medication regimen as directed 3.Follow the recommendations of the clinical staff to assure his safety 4.Seek community services for his disorder and for his living arrangements Clinical Disorders Other Conditions Psychosocial And Environmental Problems

87. John’s Behavior John b1 b3 b12 b4 b1 b7 b62 b17 b17 b17 b4 b6 b9 b17 b12 b3 b8 b8 b5 b6 b17 Goals for John: John will 1.Increase frequency of b3 and b12 2.Decrease frequency of b17 John is the totality of his behaviors and the systematic relationships among them

88. Alternative Understanding of Human Beings Sarah Pursuing personally meaningful goals While participating in culturally valued activities Using cultural tools, such as language, category schemes, mathematics, organizational supports, domain-specific strategies Mediated as necessary by individuals with greater expertise in that domain In social, cultural, and historical contexts In the presence of varied context facilitators and barriers

89. Reasons Why People Don’t Choose to Plan When They Could Adapted from Ellis & Siegler, 1997 Planning requires delay in attaining goals and Planning requires delay in attaining goals and the impulse for immediate gain is stronger than the impulse for immediate gain is stronger than the choice to delay an action the choice to delay an action Planning requires the suppression of currently Planning requires the suppression of currently activated behaviors activated behaviors Individuals are often overly optimistic about their Individuals are often overly optimistic about their success in the absence of planning, reducing the success in the absence of planning, reducing the perceived need for planning perceived need for planning Planning takes time, and speed is often valued Planning takes time, and speed is often valued over accuracy over accuracy

90. Reasons Why People Don’t Choose to Plan When They Could Generating plans is no guarantee of success and Generating plans is no guarantee of success and lack of past success influences the current choice to plan An Individual may believe that s/he has no control An Individual may believe that s/he has no control over outcomes, even if s/he does plan  Planning is often unpleasant because it is difficult or tedious or creates conflict An individual may assume someone else will make a plan for him/her An individual may assume someone else will make a plan for him/her It’s often exciting NOT to plan It’s often exciting NOT to plan

91. Helping People Choose to Plan DO NOT plan on planning in situations that have DO NOT plan on planning in situations that have historical impulsive routines in place historical impulsive routines in place Help individuals to “connect the dots”; make the Help individuals to “connect the dots”; make the outcomes associated with planning explicit and outcomes associated with planning explicit and the likely outcomes associated with not planning the likely outcomes associated with not planning equally explicit equally explicit Show the positive effects of planning for the Show the positive effects of planning for the individual in the short term and long term individual in the short term and long term

92. Helping People Choose to Plan Help the individual to make small/brief plans Help the individual to make small/brief plans with immediate outcomes  Create a culture of planning early and often  Plan with the person, not for the person

93. Goal Plan Do Review Predict

94. 94 EXECUTIVE FUNCTIONS/ SELF-REGULATION  Self-determination  Self-control  Self-management  Self-direction  Maturation

95. 95 EXECUTIVE FUNCTIONS “… those mental capacities necessary for formulating goals, planning how to achieve them, and carrying out the plans effectively” (Lezak, 1982) “…ability to maintain an appropriate problem-solving set for attainment of a future goal.” (Welsh & Pennington, 1988)

96. 96 EXECUTIVE FUNCTIONS “… the executive functions serve as an integrated directive system exerting regulatory control over the basic domain-specific neuropsychological functions (e.g., language, visuospatial functions, memory, emotional experience, motor skills) in the service of reaching an intended goal.” Gioia & Isquith, 2003

97. 97 Self-Regulation “Using thought to guide behavior” (L. Berk) “Self-regulation refers to the many processes by which the human psyche exercises control over its functions, states, and inner processes.” Vohs, K.D., & Baumeister, R.F. (2004). Understanding self- regulation: An introduction. In R.F. Baumeister & K.D. Vohs (Eds.), Handbook of self-regulation: Research, theory and applications (pp. 1-9). New York: Guilford Press.

98. 98 EF/SR Organizing and controlling action, thought, and emotion in a way that is (1) not determined by immediate environmental events, (2) not determined by immediate impulse or states of the body, (3) not determined by the control of others, (4) directed toward personal goals, (5) while taking into account environmental factors such as the goals and intentions of others  Conscious/effortful OR automatic/habitual

99. 99EF/SR  “COLD”: Self-regulation of covert cognitive and linguistic processes  Associated with dorsolateral prefrontal cortex  E.g., working memory tasks  “HOT”: Self-regulation of emotions and observable social behavior  Associated with orbital and ventromedial prefrontal cortex  E.g., delayed gratification tasks; “gambling” tasks  Interact in the real world – despite neuroanatomic and neuropsychological separability Denckla, 1996

100. 100 EF/SR: UNORGANIZED LIST  Setting and managing goals  Planning  Organizing  Initiating  Inhibiting  Self-monitoring  Strategic thinking  Problem solving  Working memory  Flexible shifting  Deliberately controlling any cognitive  Delaying gratification  Social perception  Controlling emotions  Learning from consequences  Organized sense of self

101. 101 EF/SR SYMPTOMS  impulsiveness  poor social judgment social disinhibition social disinhibition egocentrism egocentrism difficulty interpreting the behavior of others difficulty interpreting the behavior of others perseveration perseveration poorly regulated attention poorly regulated attention disorganization (in thinking, talking, and acting) disorganization (in thinking, talking, and acting) weak goal formulation weak goal formulation  ineffective planning  decreased flexibility/ shifting  slowed processing diminished divergent thinking diminished divergent thinking concrete thinking concrete thinking immature problem solving immature problem solving weak self-monitoring weak self-monitoring inefficient responses to feedback/ consequences inefficient responses to feedback/ consequences reduced initiation reduced initiation dulled emotional responses dulled emotional responses

102. 102 EF: FACTOR ANALYSES  Several attempts have been made to organize lists of EF symptoms using factor analytic procedures.  The variety of lists recommends caution in interpretation!!  From an intervention perspective, these results are not especially useful – for both technical and clinical reasons.  Neuropsychological separability does not necessarily recommend intervention separability  Factor analyses are vulnerable to the limitations of the tests administered

103. 103 EF/SR: Theory Construction R. Barkley Primary: Behavioral Inhibition Working Memory: Nonverbal Internalization of Speech: Verbal Working Memory Self-regulation of affect, motiv -ation, arousal Reconstitution: Creativity, organization Motor control/fluency/syntax Inhibition of task-irrelevant responses Execution of goal-directed responses Sensitivity to feedback Flexibility, etc.

104. 104 EF/SR: FUNCTIONAL DEFINITION Based on analysis of strategic action  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 and acting  Flexible shifting, adjusting, benefiting from feedback

105. SR/EF CHECKLIST GENERAL CONSIDERATIONS 1. Is intervention in the areas that fall under the heading "executive functions" structured around the individual's own meaningful goals? 2. Is intervention infused into everyday activities? Are all everyday people oriented to how they can facilitate improved executive functions? Are all everyday people aware of the dangers of learned helplessness? 3. Are everyday people aware of the strategies that the individual is being taught or is expected to use? 4. Is successful performance in the areas grouped under this heading richly and naturally rewarded? Is the individual held responsible for effective strategic performance? 5. Is the individual given ample opportunity to identify and solve his or her own problems (with guidance if necessary)?

106. SR Checklist (cont’d) 6. For individual's who are young or very concrete, are executive function tasks structured around concrete physical activities (versus abstract or cognitive activities)? 7. Do everyday people in the environment routinely model expert use of executive functions? 8. Is the individual given sufficient practice so that strategic behavior becomes automatic? 9. Are everyday people in the environment supportive of strategic or compensatory ways to accomplish tasks? 10. Does the individual respect a strategic or compensatory approach to everyday problems? If not, is appropriate help/counseling provided? 11. Are everyday people in the individual's environment fully aware of possible limitations in the individual's executive functions (esp., initiation and inhibition) so that they do not misinterpret behavior?

107. Self-Awareness of Strengths and Needs  Is the individual maximally engaged in identifying what is easy and hard to do, and what makes activities easy or hard?  Is the individual given opportunities to compare performance when an activity is completed in a usual way versus when it is completed with special strategic procedures?  Does the individual keep a journal in which strengths and needs are recorded?  Is the individual given opportunity to identify strengths and needs in others, and strategic procedures that others may use (e.g., peer teaching)?  Is the individual given appropriate informative feedback (e.g., peer feedback, video feedback, confrontational feedback if appropriate)?

108. Goal-Setting  Is the individual routinely asked to predict how well he will do on activities?  Are predictions recorded in journals and compared with actual performance?  Does the individual maximally participate in rehabilitation/special education goal setting? Is adequate support provided if this is difficult?  Are intervention activities structured around the individual's personal goals?

109. Planning  Does the individual participate maximally in planning his or her intervention activities?  Is a planning guide available, if needed?  Does the individual begin the day by preparing a plan on a planning board or in a journal? Does the individual begin each activity by preparing a plan?  Do therapy activities include attempts to plan meaningful complex events (e.g., parties, outings, etc.)?  Does the individual participate maximally in long-term future planning? rehabilitation planning? IEP development

110. Self-Initiating  Do everyday people give the individual opportunities to initiate and wait an appropriate length of time? Are signals available to remind the individual to initiate activities?  Do the activities that the individual engages in make appropriate demands on the individual's ability to initiate (e.g., board games may require little initiation; conversations may require much initiation)?  Are all forms of institutional "learned helplessness" avoided?  Are prosthetic initiators available if needed?  If initiation cues are necessary, are they provided as much as possible by peers versus staff? Is nagging avoided?

111. Self-Inhibiting  Do everyday people give the individual opportunities to inhibit that are realistic in their demands?  Do the activities that the individual engages in make appropriate demands on the individual's ability to inhibit (e.g., unstructured and unfamiliar activities in a distracting environment require considerable inhibition)?  If inhibition cues are necessary, are they as subtle as possible and provided as much as possible by peers versus staff? Is nagging avoided?

112. Self-Monitoring/Evaluating  Do everyday people give the individual opportunities to self-monitor and evaluate performance? If cues are necessary, are they subtle? Is nagging avoided?  Is the individual maximally involved in charting his own performance? keeping a journal in which performance is recorded? graphing performance?  Is the individual routinely asked to fill in a form regarding his own performance: What Works? and What Doesn't Work?

113. Intervention Goals Sarah will successfully complete ___ meaningful task, with ___ supports, possibly using ___ “tools/strategies”, in ___ context (setting, people, activities), in order to achieve ___ goal. Possibly focusing intervention attention on some specific aspects of cognition, communication, social skills, behavioral self-regulation, or educational/vocational skills – aspects that are either particularly weak or particularly important for Sarah.

114. PRINCIPLE: THE PERSON IS THE CORE OF ALL INTERVENTION AND SUPPORT EFFORTS  Participation in goal setting and planning  Making big plan  Daily goal setting, planning, reviewing  Participation in the assessment process  Participation in deciding activities  Which person?? Helping the person to create an identity that is:  Stable  Positive  Nondisability/non-problem oriented  But inclusive of hard strategic effort

115. Medical/Expert Model: I set your goals I make your decisions “Shallow” Person-Centered: “Whatever you Say!!” “Mature” Person-Centered: Organize supports around goal- directed choices Thesis: External Control Anti-thesis: Enable Impulsiveness Synthesis: Facilitate goal- directed choice Apparently irresolvable conflict Goal-Directed Identity

116. Which Person?? “Person-Centered” Supports  “Person-centered” does NOT mean never having to say, “That’s not a good plan!! --- That’s not a choice – that’s just impulse!!”  Administrative challenges:  Who is authorized to help the person distinguish between choice and impulse?  Who facilitates goal-directed choosing and planning?  What are the scripts for staff?

117. PRINCIPLE 2: INTERVENTIONS AND SUPPORTS ARE ORGANIZED AROUND PERSONALLY MEANINGFUL ACTIVITIES “In the absence of meaningful engagement in chosen life activities, all interventions will ultimately fail”  Option: School, work, volunteer experiences, family responsibilities  Option: Preparatory skill development related to school, work, volunteer experiences  Option: Meaningful projects!!

118. Projects  Personally meaningful goal = product SENSE OF SELF AND MOTIVATIONAL THEMES  Expert role; helper/producer role  Intrinsic motivation; meaningful engagement  Anti-egocentrism  Relevance, anti-oppositionality  Awareness of strengths and needs SOCIAL/BEHAVIORAL THEMES  Meaningful context for practice of social/ interactive competencies  Meaningful context for practice of collaborative, cooperative effort and behavioral self-regulation COGNITIVE THEMES  Deep processing  Planning and organizing  Meaningful context for practice of all cognitive and “Executive Function” processes  G-O-P-D-R  Compensatory strategies  Integration of activity over time – day to day  Integration of several contexts

119. PRINCIPLE: CONTEXTUAL SUPPORTS ARE CRITICAL TO SUCCESS Most critical to success:  Effectively trained “everyday people”  Collaboration between:  Clinicians and educational staff  Natural and paid supports  Elaborative supports:  Designed to expand domain of activity beyond disability supports  Designed to improve thinking and decision making  Feedback: authentic and context-sensitive

120. PRINCIPLE: REDUCTION OF SUPPORTS IS PART OF THE PLAN  Supports must be adjusted to fit needs and abilities  Systematic reduction of supports is planned from day 1  It is a goal of educational programs to empower people to succeed with natural supports

121. PRINCIPLE: POSITIVE EVERYDAY ROUTINES ARE THE CONTEXT FOR PURSUIT OF MEANINGFUL GOALS  Collaborative design of successful everyday routines  Recognition of adherence to routines and plans  Ongoing reinforcement of planning, routine development, and maintenance of positive routines: CELEBRATION of everyday success! “Routine is despair’s sly assassin”

122. PRINCIPLE: FEEDBACK IS CONTEXT- SENSITIVE AND MEANINGFUL  Skill development within the context of meaningful pursuit of goals  Natural and logical feedback in relation to pursuit of meaningful goals  NOT: That’s appropriate/inappropriate  RATHER: That works/doesn’t work in relation to your chosen goals  General structure for all activities: GOAL – OBSTACLE – PLAN – DO -- REVIEW

123. PRINCIPLE: ASSESSMENT IS ONGOING AND CONTEXT-SENSITIVE  Requirement of functional behavior assessment  Collaborative hypothesis testing  Engagement of the person in assessment  Assessment informs intervention/support informs assessment informs intervention/support informs assessment ……………………

124. PRINCIPLE: COMPONENTS OF LIFE MUST BE INTEGRATED  Individuals who are fragmented should live within integrated systems of support  Domains of integration  Across everyday contexts  Across professionals and between professionals and everyday people

125. PRINCIPLE: THE ULTIMATE GOAL FOR PARTICIPANTS IS EFFECTIVE SELF- REGULATION WITHIN A MEANINGFUL LIFE  Meaning is at the core of decision making  A primary focus of intervention and support is the development of self- regulation/"self-coaching"

126. Project Based Intervention  Present a project in terms of helping others identify important information for transitions  Provide a context to evaluate and plan for the “big picture” with student and family  Provide a context to collaborate, as consultants, with the team (e.g., the aide, classroom teacher, vocational teacher, and parents).

127. Project Approach: Rationale  Organizational impairment  Superior involuntary learning  Weak elaborative encoding  Need for situated learning  Need for errorless learning  Need for routine learning

128. Project Approach Rationale (cont’d)  Internalization of mediated interaction  Egocentrism  Unawareness  Intrinsic motivation  Oppositionality  Sense of self  Self-esteem

129. Project Approach  Meaningful goal; product  Deep processing  Planning and organizing  Meaningful context for practice  Integration of activity over time  Integration of several contexts  Expert role  Helper/producer role

130. Teaching Positive Attribution UNHELPFUL ATTRIBUTION  “I can’t do anything well”  “Teachers don’t like me”  “Other kids are lucky”  “Sometimes I get it; sometimes I don’t; I don’t know why”

131. Teaching Positive Attribution HELPFUL ATTRIBUTION  “When I work hard and use my strategies, I do OK; When I don’t, I do badly”  “Reading is harder for me than for other students, but I can get it if I give myself enough time and use my strategies.”

132. Teaching Positive Attribution: Procedures  “Product Monitoring”  Framing  Self-Monitoring  Hero Identification  Procedures associated with “learned optimism”

133. EXPERIMENT ROUTINE “THIS WAY OR THAT?”  Identify issue or conflict  Try both ways  Identify most successful  General reassurance

134. EF SCRIPTS: DELIVERY  Conversational, non-threatening interaction  Well-selected language  Avoid boredom, irritation  Mainly positive: “easy” “non scary” “not a problem” “not a big deal”  Massed and distributed practice (hundreds!!)  Embedded in meaningful activity  Across all everyday partners

135. PROBLEM-SOLVING SCRIPT  Identify issue or conflict  State the reason  Generate a solution/strategy  General reassurance

136. HARD TO DO/EASY TO DO SCRIPT  Identify task as hard or easy  State the reason  Generate a strategy (if hard)  General reassurance

137. BIG DEAL/LITTLE DEAL SCRIPT  Identify the issue as a big deal or a little deal  State the reason  Generate a strategy (if a big deal)  General reassurance

138. SCARY/NOT SCARY SCRIPT  Identify situation as scary or not scary  State the reason  Generate a solution/strategy  General reassurance

139. Problem Solving/Strategic Thinking  Is the individual maximally involved in solving everyday problems as they arise? Are everyday people thoroughly oriented to the importance of problem solving?  Is the individual maximally engaged in selecting strategies to overcome obstacles and achieve important goals?  Is there an appropriate amount of external support for strategic thinking?  Does the individual have a form that cues the appropriate kind of strategic thinking?  Do everyday people in the environment expect and cue strategic performance?  Do everyday people in the environment avoid learned helplessness, that is, do they resist solving all of the individual's problems?  Is there consistency among staff and family members in how problem-solving tasks are presented and in the kinds of external problem-solving support that are provided? Is there consistency in reducing external support as the individual becomes increasingly independent in problem solving?

140. ROUTINES Repetition creating temporal structure to improve memory Repetition creating temporal structure to improve memory about relevant past events about relevant past events Cognitive predictions about what happens next Cognitive predictions about what happens next Natural occasions for promoting cognitive growth Natural occasions for promoting cognitive growth An impetus for improvisation when trying to avoid An impetus for improvisation when trying to avoid a negative outcome a negative outcome are a necessary prerequisite forPlanning

141. Routine is despair’s sly assassin.

142. ConcreteRoutines Picture Routines Picture Routines Written Routines Written RoutinesInteractionRoutines Language Routines Language Routines Activity Sequencing Activity Sequencing Routines to Deal with Changes in Routines What I do when what I expected What I do when what I expected to happen doesn’t happen to happen doesn’t happen

143. “Much of our cognitive life may be the product of highly automated routines.” - Gerald Edelman

144. Steps to Organize Routines of Everyday Life 1.Identify successful and unsuccessful routines of everyday life. What’s working, what’s not working? 2.Identify changes that have the potential to transform unsuccessful routines into successful routines (including changes in the environment and the behaviors of others.) 3.Identify how changes in routines include activities that are motivating to the individual and everyday people.

145. Steps to Organize Routines of Everyday Life 4.Implement needed supports to organize routines so that the individual experiences success and receives intensive practice in context. 5.Systematically withdraw supports and expand contexts as much as possible.

146. Goal Plan Do Review Predict

147. Key “Executive System” Concepts That Help Individuals Learn Self-Regulation Hard - Easy Big Deal - Little Deal Ready - Not Ready Scary - Not Scary Like - Don’t Like Choice - No Choice

148. Interaction Scripts for Routines Making Decisions Making Decisions About the Goal About the Goal “What’re you going to do?”“What’re you going to do?” “What are we here for?”“What are we here for?” “How will we know we’re done?”“How will we know we’re done?” “We’ll know we’re done when“We’ll know we’re done when it looks like this... “

149. Making Plans Making Plans “OK, so what’s the plan?”“OK, so what’s the plan?” “What’ll you need to get this done?”“What’ll you need to get this done?” “How will you and I know you’ll“How will you and I know you’ll need help?” “What will help look like?”“What will help look like?” “Don’t tell me what you don’t “Don’t tell me what you don’t want, tell me what you do want.” “OK, so what do you want me to do?”“OK, so what do you want me to do?”

150. Making Decisions About Ease or Difficulty Before Beginning Difficulty Before Beginning “Do you think this will be hard or easy?”“Do you think this will be hard or easy?” “If it’s hard, then what’ll you need?”“If it’s hard, then what’ll you need?” “Have you ever done this before?“Have you ever done this before? What happened? “I don’t think I could do this! How do“I don’t think I could do this! How do you know that you can?” “Whaddaya think? Big deal or little deal?”“Whaddaya think? Big deal or little deal?”

151. Coaching Through Problems “You look upset, is there anything“You look upset, is there anything I can do?” “OK, you’re not ready. No problem;“OK, you’re not ready. No problem; just let me know when you’re ready. “I’ll know you’re ready when you“I’ll know you’re ready when you look like this...” “I’ll wait.”“I’ll wait.” “You know we’ve gotta figure this“You know we’ve gotta figure this out, let’s try... “ “I know it’s hard, but we’ve got“I know it’s hard, but we’ve got to do this.”

152. Coaching in Context “So, how’s it going?”“So, how’s it going?” “Is that helping you? Not helping?”“Is that helping you? Not helping?” “Is there anything else you can do?”“Is there anything else you can do?” “Is there anything I can do to help you?”“Is there anything I can do to help you?” “So when are you going to start?”“So when are you going to start?”

153. Review What Occurred Review What Occurred “So how’d it go?”“So how’d it go?” “How’d you do?”“How’d you do?” “Tell me exactly what happened...“Tell me exactly what happened... and then what?” “What do you think other people“What do you think other peoplethought?” “What were you thinking when you...”“What were you thinking when you...” “Next time you do this, what’ll you do “Next time you do this, what’ll you do differently? The same?” “What helped?“What helped? “What didn’t help?”“What didn’t help?”

154. An Important Goal of Intervention: Learning to Recognize Internal States  Using some commonly understood method of communicating “my” mood/ feelings/health, etc. - Red – Yellow – Green - A thermometer - Rating Scales

155. I’m feeling really lousy I’m feeling great Recognizing and Communicating My Internal State

156. 123456 78910 Cool Zone – Blue ZoneYellow ZoneRed Zone Peaceful Destructive Past the Red Line Red in the face Staring Lips clenched QuietSwearing PERSEVERATION Aaron’s Indicators: Staff Scripts: “Use your strategies” - take a break and move away - talk about what your feeling - listen to music “Stop and breathe”“Clear the deck” - Get somewhere else quiet Use the “Hard – Easy” Script -“Aaron is this hard or easy?” - “OK, if it’s hard, no problem I’ll give you some help.” Use the Ready – Not Ready Script -“Aaron you’re not ready to do this.” -“I’ll know you’re ready when you look like ________.” Following directions Making eye contact AARON’S RATING SCALE Prior to, and following, each activity Aaron and his staff will evaluate his general mood using this scale. In addition, the scale can and should be used during activities as a way of helping Aaron recognize his mood changes, and the causes for those changes.

157. Constructing an identity that is meaningful and sustainable is a primary goal of intervention

158. Each waking day is a stage dominated for the good or ill, in comedy, farce, or tragedy, by a dramatis persona, the “self”. And so it will be until the curtain drops... Although multiple aspects characterize the conscious self, this self is a unity.” - Charles Sherrington, 1946 - Charles Sherrington, 1946 The Integrative Action of the Nervous System

159. Alliances are Critical to Success 1.When working with others in a concordant manner the intensity, consistency, and duration of services improves. 2.There is an increase in the probability of generalization and maintenance of positive change (Brown’s Rule of Three: Three people, three places, three times.) 3.There is a necessary infusion of reality, common- sense, and a functional focus of interventions. 4.“All of us are smarter than any one of us.”

160. Creating Alliances: Three Rules of Thumb for Professionals 1.Demonstrate respect all the time, especially when interacting with someone that you don’t like (or who doesn’t like you!). 2.Seek the insights of everyday people - find the hidden experts and use their expertise. 3.Keep your hat in your hand; never forget you will always be a visitor in the life of the person with whom you are working.

161. PRINCIPLE: BEHAVIORAL CONCERNS ARE ADDRESSED VIA POSITIVE BEHAVIOR SUPPORTS  Environmental focus: Aspects of the environment – settings, people, activities, demands – are primary contributors to behavior  Antecedent focus: Behavior plans largely focus on antecedents and are designed to facilitate success  Consequences are logical and meaningful  Skill development: Skills are developed to achieve meaningful goals

162. THAT’S WHAT I AM! THAT’S WHO I AM! RIGHT OR WRONG, I CAN’T CHANGE THAT CARLITO (AL PACINO), CARLITO’S WAY

163. “I’ve lived a very dysfunctional life, and I know that that life has shaped and molded me into the person I am today. I want to reshape myself.” - Lloyd K. - Lloyd K.

164. “The self is not something ready made but something in continuous formation through choice of action.” - John Dewey

165. SENSE OF SELF FOR INDIVIDUALS WITH CO- EXISTING DISABILITIES  Perplexity  Unawareness or denial: Retention of preinjury self-concept  Fragmentation  “I am a victim” (passivity; depression)  “I refuse to be a victim” (anger; aggression)  “I’ve changed; I’ve got my work cut out for me” (resolve)

166. “IDENTITY MAPPING”  Identification of goals  Identification of image, hero, metaphor  Organization of identity description  [Creation of “identity map”]  Supported practice  Modification of others’ support behavior  Possibly meaningful project

167. IDENTITY CONSTRUCTION Helping individuals with disability construct a sense of personal identity that is:  Satisfying/compelling  Organized  Adequately realistic AND that includes the hard strategic effort needed to be successful with a disability

168. An Identity Map Reconstructing/Constructing Identity POSITIVE IDENTITY METAPHOR FACTS FEELINGS APPEARANCE GOALSPROCEDURES What has this person done? What does this person look like? How does this person feel? What will I need to do? What am I trying to accomplish?

169. Identity Mapping: Cautions  Professional competence  Emotional fragility  Professional imposition  Cognitive prerequisites  Meaningful language

170. Identity Mapping: Cautions  Dangerous metaphors  Negative use (e.g., “nagging”)  Getting stuck; flexibility  Heroes and victims  Time post injury

171. Goals: Simply comply Others set goals No goals for self Feelings: Anger at driver and all authorities Inadequacy, dependence Hopelessness, frustration Action strategies: No need for strategies; others take responsibility No sense of responsibility Other people’s charge Appearance: Crutches, casts, etc People Therapists, physicians, aides Places Hospitals, clinics Facts: TBI: 1991 Many injuries 11 weeks: hospitalization Casts, scars, crutches Multiple surgeries Jason the Victim

172. Goals: Freedom Independence Retribution (driver, any source of control) Victory!!!! Feelings: Anger/Oppression Power/Control Competence/Independence Zeal for justice Action strategies: When provoked, scorched earth policy Demonstrate ability and power Demonstrate others wrong Experiment with new things Try therapy (unsuccessful) Appearance: Attempt to project power People Everyday people Places Everyday places Facts: Former marine (Exaggerated) sense of Improvement Disjointed life in disarray Jason the Marine

173. Goals: First rate production Make a clear statement Define self Feelings: Satisfaction Accomplishment Growth Control Focus Action strategies: Contemplate versus react Plan for success (daily strategy formulation sessions; daily plan sheets; barometer) Script in advance Practice taking alternative perspectives Goal-Plan-Do-Review Use supports wisely Appearance: Appropriate to the context People Support people Non-conflict people Places Facts: Actor willing to be directed Director Mayor Producer Successful Clint Eastwood

174. The Job: Help people to learn to develop, and tell THE STORY Not simply report the news.

175. Four Lessons to Live by: Hope is an essential part of any successful plan of support. Form follows function. Think about what you need and then create a way for that to happen in a flexible manner. The more you try to force something or someone to change, the more it (or he or she) changes you. When all else fails, a sense of joy and a sense of humor can get you through a whole lot!