Presentation on theme: "Strategies & Interventions"— Presentation transcript:
1Strategies & Interventions Brain Injury and Executive FunctioningRachel Toplis, PhDDr. Jonelle NeighborRefer to earlier presentations.
2Executive 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.wwline.orw.ldong
3Some 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!
4External 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.
5Executive Functions: Functional Definition Self-awareness of strengths and limitations (what’s hard to do; what’s easy to do)Goal settingPlanning/organizingInitiatingInhibitingSelf-monitoring and evaluatingStrategic thinkingFlexible shifting, adjusting, benefiting from feedback(Feeney, 2005)
6Examples of Functional Executive Skills Attention and ConcentrationNew LearningMental ProcessingEmotional ControlReasoning and Problem SolvingOrganizational SkillsMemoryInitiationFunctional executive skills. In the literature others are identified such as persistence, impulsiveness, time management etc.
7Executive Functioning Difficulties SOCIAL:poor social judgmentsocial disinhibitionEgocentrismdifficulty interpreting the behavior of othersBEHAVIORAL:Perseverationimpulsivenesspoorly regulated attentiondisorganization (in thinking, talking, and acting)dulled emotional responsesPROBLEM SOLVING:decreased flexibility/ shiftingslowed processingdiminished divergent thinkingconcrete thinkingimmature problem solvingweak self-monitoringinefficient responses to feedback/ consequencesreduced initiationweak goal formulationineffective planning
8What disabilities are impacted by dysexecutive functioning? Traumatic Brain InjurySpecific Learning DisabilityAttention Deficit / Hyperactivity DisorderAutismTourette’s SyndromeSchizophreniaDepressionObsessive Compulsive DisorderDementiaEtc…..
10Attention and Self Control 6-12 mosimpulse control and self inhibitionEarly inhibition begins to be demonstrated1-2 yrsAbout 1 year can inhibit a response and shift to a new responseSome self monitoring and beginning ability to identify errors3-6 yrsGeneral increases in attention, self control, concentration and inhibitionGradual lessening in impulsivityOccasional preservative behaviorsBy 6 yrs is able to resist distractions and increase length of attention span7-9 yrsAble to screen out irrelevant stimuli from selected target for attention
11Attention and Self Control continued 10 yrsBetter able to pay attention to a selected target and screen out unwanted informationImpulse control is nearing adult levels11-12 yrsAble to monitor and regulate actionsAttention is fairly matureLimits perseveration similar to an adultTemporary increase in impulsive behaviorsAdolescencePerseveration is rareWorking memory increases dramaticallyAs cited in Richard, G.J., Fahy, J.K., (2005). The source for Development of Executive Functions. East Moline, IL: Linguisystems
12Cognitive Flexibility Helps studentsinterpret information in multiple wayschange approaches andselect a new strategy if the first one is not working.Students must use knowledge from a variety of perspectives used inreading comprehensionperspective taking in written languageshifting topics of conversationtopics of study within the school day
13Cognitive Flexibility and Purposeful Behavior 2-4 yrs2 ½ yrs. knowledge of rulesunable to shift or alter behaviorrely on perseveration3 yrs can shift behaviors to adapt to knowledge of rules butonly to one rule at a time4 yrs begin to shift between two simple task setshave difficulty when response sets increase in complexityGreater task completion because of increased mental flexibility5-6difficulty shifting between multiple rules with verbal prompts6 yr olds have sharp increase of mental flexibilityPerseveration decreasesIncreasing ability to learn from mistakes and generate new strategies for solving simple problems
14Cognitive Flexibility& Purposeful Behavior 7-9 yrsstruggle with shifting behavior sets that are contingent on multiple demands8 yrs increasedfocused, sustained attention,ability to shift attention9 yrs more success shifting from rules or sets depending on multiple or changing demands10-12 yearsImprovement in ability to shift between multiple tasksdecline in perseveration.greater ability to learn from mistakescreate alternative strategies for multidimensional problemsAdolescenceCognitive flexibility is fairly maturePerseveration is rareFlexibility or the ability to change between performance demands and initiate deliberate behaviors is greatly improved
15Strategies and Interventions for specific areas InhibitShiftEmotional ControlInitiateWorking MemoryPlanningOrganization of materialsSelf MonitoringBased on the work of Gerard A. Gioia, Peter K. Isquith, Steven C. Guy & Lauren Kenworthy.
16Behavioral 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.
17Emotional 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.
18Working 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.
19Planning – 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.
20Organization – 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.
21Inhibit 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.
22Inhibit 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
23Shift 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
24Shift 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).
25Emotional 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.
26Emotional 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.
27Initiate 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.
28Initiate 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.
29Working 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.
30Working 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
31Planning 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.ScriptsSQ3R. 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.
32Planning 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.
33ScriptsEncourage 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 issue2. State the reason3. Offer a strategy4. General reassurance.
34Scripts 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.
35Organization 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 notesGraphic organizersNote-taking templatesGuided notes
36Organization 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 plannersWriting checklists.
37Self 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 forhow to check for these errorsexactly how to correct the errors
38Self 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
39Goal-Plan-Do-ReviewGOAL: 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?
40Goal-Plan-Do-ReviewPLAN: 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?
41Goal-Plan-Do-ReviewDO: [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?
42Self 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.
43Mental 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.
44Mental ProcessingTry 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.
45Attention and FocusSelf 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.
46Attention 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.
47Attention and Focus Limit Noise Remove distractions Provide concrete visual cuesLimit amount of info on a page.Adjust assignments.Focus on most salient aspect of lesson.Maintain brisk pace.Repeat instructions
48Attention 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.
49Great Resource www.cokidswithbraininjury.com Pull up matrix and review MEMORY VISUALSPATIAL ORGANIZATION
50ResourcesBrainSTARS Brain Injury: Strategies for Teams and Re-education for Students.Dise-Lewis, Lohr Calery & LewisHands on manual broken into three partsDefining brain injury, how it affects children at different developmental stages.Specific problems and strategies.Advocacy and community resources.
51LearNet: www.bianys.org/learnet REAP concussion management plan (Reduce-Educate-Accommodate-Pace).Cokidswithbraininjury.comOffers 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.
52Resources 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.