AssessmentandIntervention:ExecutiveFunctionsLAURAWILSON,PHD,CCC-SLP, CBIST

9/27/19

DisclosuresIamafull-timeemployeeatTheUniversityofTulsa

KSHAisprovidinganhonorariumformyparticipationtoday

IamaCertifiedBrainInjurySpecialistTrainerthroughtheACBIS/BIAA

Nootherfinancialornon-financialrelationshipstodisclose

LearningObjectives1. identifyformalandinformalassessmenttoolsforevaluatingexecutivefunctionskills

2. describeevidence-basedinterventionsforexecutivedysfunctionfollowingtraumaticbraininjury

3. decideontheappropriateinterventiontoaddressexecutivedysfunctionincaseexamples

Whatareexecutivefunctions?“Thegroupofcomplexmentalprocessesandcognitiveabilities◦ (suchasworkingmemory,impulseinhibition,andreasoning)

thatcontroltheskills◦ (suchasorganizingtasks,rememberingdetails,managingtime,andsolvingproblems)

requiredforgoal-directedbehavior.”

Merriam-Webster,2019

ButwhatSPECIFICALLYaretheseexecutivefunctions?

Constantinidou etal.,2012

•Planning/goalformulation•Initiationandallocationofattentionresources•Impulsecontrol

Planning/initiation

•Behaviormaintenance•Cognitiveflexibility

Maintenance/flexibility

•Self-awarenessofstrengthsandweaknesses•Self-regulationbasedongoals•Effectiveperformance

Regulationandeffective

performance

Andhowdotheyrelatetometacognitionandself-monitoring?Self-monitoring◦ IswhatI’mbuildingmatchingwhattheinstructionssayitshouldlooklikesofar

◦ It’sanevaluationDURINGtheactivitythatprovidesinternalfeedback

Executivefunctions◦ Implementastrategy?◦ Decidewhethertoretracesteps,askafriendtocomehelp,startover,orjustgrabanextrascrewfromthetoolboxandmakeitwork

Selfmonitoring+executivestrategies=self-regulationofbehavior

Overtime,experienceshelpmoldmetacognitivebeliefs

Kennedy&Coehlo,2005

Functionally,whatdobreakdowns inexecutivefunction looklikeforyourpatients?

Note:WearegoingtodiscussexecutivefunctionsthroughthelensofTBI,butdeficitsarenotuniquetoTBI!

Whythefocusondysexecutivesymptoms?

Deficitsinexecutivefunctionsarepredictiveof

• Reducedresponsetotherapy• Worseoutcomesforpatients(greaterdisability,lowercommunityintegration,decreasedratesofreturntowork)

• Worseoutcomesforcaregivers(highercaregiverburden)

Robertson&Schmitter-Edgecombe, 2015;Wise,Ownsworth,&Fleming, 2005

Frontallobesyndrome?Executivefunctiondeficitsoftenlinkedtolesionsinthefrontallobe,particularlyprefrontalcortex

Wehaveabandonedfrontallobesyndromebecause…◦ dysfunction canalsobeseenwithdamagetothalamus,basalganglia,andwhitematterpathwaysconnecting frontallobetoothercorticalstructures

◦ frontallobedamagecanalsobeobservedwithoutconcomitantexecutivedysfunction

Leh,Petrides,&Strafella,2010

AwarenessLackofawarenessofdeficits=anosognosia

Poorawarenesscandecreasemotivation,causesafetyissues,andperhapsinterferewiththerapeuticgains

Lackofawarenesscanprotectagainstdepression

Toglia &Kirk,2000

Self-Knowledge

Similartointellectualawareness

Understandingofone’sown

strengthsandweaknesses

Onlineawareness

Similartoemergentawarenessandanticipatoryawareness

Taskandsituationaldependence

Assessment

PurposeofassessmentCreateastrengthsandweaknessesprofile

Identifypatientgoals

Guidetreatment(remediation,compensation,counseling)

Identifybaselineperformancetotrackprogress

Note:Wearefocusedonindividualswhoarepost-acuteandemergedfromPTA

Constantinidou etel,2012

AssessmentconsiderationsPerformanceonformalexecutivefunctionassessmentsmaybeimpactedbyothercognitive-communicative,neurobehavioral,andmotordeficits

Mostformalassessmentstargetexecutivefunctionasawholev.targetingspecificimpairments(thatis,theyarenotspecific)

CannotrelySOLELYonself-reportquestionnaires(supplementwithinterviewsandwithreportsbysignificantothers)

Limitedecologicalvalidityofmanystandardizedassessments

Constantinidou etel,2012

Whypoorecologicalvalidity?Reorganize- betterandworseThetestingenvironmentprovidesstructurethatsupportsexecutivefunctions

Onlyabriefsnapshotofbehavior

Testsmaynotbesensitivetodeficitsinindividuals’strongpremorbidskills

Motivationmaybelimitedduringtesting

Testsmaynotallowfortheuseofcompensatorystrategies

Constantinidou etel,2012

StandardizedTestsMULTITEST EXECUTIVEFUNCTIONBATTERIES

BehaviouralAssessmentoftheDysexecutiveSyndrome(BADS)

FunctionalAssessmentofVerbalReasoningandExecutiveStrategies(FAVRES)

Delis–KaplanExecutiveFunctionSystem(D-KEFS)

EXAMPLESOFTESTSCOVERINGCOMPONENTSOFEFStroopColorandWordTest

COWAT

TrailMakingTest

Designfluency

WisconsinCardSortingTest

TowerofLondon

Snyder,Miyake,&Hankin,2015;MuellerandDollaghan, 2013

ExamplesofQuestionnaires,RatingScales,andInterviews

BehaviorRatingInventoryofExecutiveFunction(BRIEF)

DysexecutiveQuestionnaire(DEX)

BrockAdaptiveFunctioningQuestionnaire(BADQ)

CognitiveFailuresQuestionnaire(CFQ)*

AwarenessQuestionnaire(AQ)**

PatientCompetencyRatingScale(PCRS)**

Self-AwarenessofDeficitsInterview(SADI)*

*=freelyavailableonline;**=specificallyavailableonCOMBIwebsite:http://tbims.org/combi/list.html

ExamplesofassessmentswithmoreecologicalvalidityNaturalisticActionTest(Schwartzetal.,2002)◦ maketoastandcoffee,gift-wrapapresent,andpackachild’s lunchboxandschoolbag◦ Looksatcompletionofeachtest(accomplishment) anderrorrates

ExecutiveFunctionPerformanceTest(Baum,Morrison,Hahn,&Edwards,2007)◦ makesomeoatmeal,usethetelephone, takesome“fake”medication,andpaysome“fake”bills◦ examinesinitiation,organization, sequencing, judgment andcompletion ofeachtask

ExecutiveFunctionRoute-FindingTask(Boyd&Sautter,1993)◦ Findanunfamiliarlocationwithouthelpfromclinician◦ Taskunderstanding, informationseeking, retainingdirections,errordetection,errorcorrection

InterventionENVIRONMENTALSUPPORTS/ASSISTIVETECHNOLOGY

METACOGNITIVESTRATEGYINSTRUCTION

EnvironmentalsupportsandassistivetechnologyforcognitionThepurposeistocompensateimposeorganizationexternally tocompensatefordeficits

BUTCAUTION:

THESENEEDTRAINING,TOO!

Thesearetaskandsituation-specificinterventions(thatis,wedonotexpectgeneralization inanyway)

Sohlberg, Kennedy,&Powell,2005

Metacognitivestrategyinstructioncomponents◦ Identifysituations inwhichdeficits inexecutivefunctionleadtobreakdowns

◦ Identifywhatisdrivingthebreakdown◦ Picktheappropriatestrategy(examplesforthcoming!)

◦ Modeltheuseofthestrategyduringthetask◦ Practicewiththeclient(whileverbalizingthestrategy)

◦ Cueasnecessary(writtenorverbal,errorlesslearning)

◦ Fadeverbalizations◦ Considergeneralizationofstrategy

(Sohlberg&Mateer,2001,pg.257)

PredictionofperformanceandreviewofperformanceareCRITICALcomponents,especiallyforthosewithawarenessdeficits.

Kennedyetal.,2008;Ciceroneetal.,2011;Tateetal.,2014

GoalmanagementtrainingWorksontheoryofgoalneglect

Amanual-basedintervention

BriefversionshavebeenshowntobeeffectiveinimprovingtaskperformanceforindividualswithTBI

Doesnotappeartoimproveskills

BestifusedinCOMBINATIONwithotherinterventions

Levineetal.,2000;Krasny-Pacini,Chevignard,&Evans,2014

Problemsolvingtraining1.problemdefinitionandformulation

◦ What’sthegoal?◦ Whataretheconstraints?

2.generationofalternatives◦ Identifypossible solutions

3.decisionmaking◦ Prioritizestrategiesbasedon

preference/successlikelihood◦ Createbackupplan

4.solutionimplementationandverification◦ Createstepsofaction◦ Gathermaterials◦ Startthesteps◦ Self-monitoreachstep◦ Modifyasnecessary◦ Usebackupstrategyasneeded◦ Alwayscheckbacktogoal◦ Reviewwhatworkedandwhatdidnot

Vasetal,2011;Kennedy&Coehlo,2005

StrategicMemoryandReasoningTraining(SMART)Gistreasoningincludes:

“(a)strategicattention(inhibitinglessrelevantinformation),

(b)integratedreasoning(abstractingconceptsbycombiningpre-existingknowledgewithrelevantfacts),and

(c)innovation(flexiblyandfluentlyderivingmultipleinterpretationsbyinterpretingtheinformationfromdifferentperspectives)”

Interventionincludesfocusonthefollowingstrategies:◦ Filter◦ Integration◦ Focus/chunk◦ Link

◦ Innovation◦ Zoom◦ Generalize

Resultsinimprovedperformanceonexecutivefunctiontasks,andalsoimprovedfunctionalperformance

Vasetal.,2011,p.226

Casestudy

ReferencesBaum,C.M.,Morrison,T.,Hahn,M.,&Edwards,D.F.(2007).ExecutiveFunctionPerformanceTest:TestProtocolBooklet. St.Louis,MO:WashingtonUniversity.

Boyd,T.M.&Sautter,S.W.(1993).Route-finding:Ameasureofeverydayexecutivefunctioninginthehead-injuredadult.AppliedCognitivePsychology,7,171-181.

Cicerone,K.,Langenbahn,D.M.,Braden,C.,Malec,J.F.,Kalmar,K.,Fraas,M.,Felicetti,T.,Laatsch,L.,Harley,J.P.,Bregquist,T.,Azulay,J.,Cantor,J.,&Aashman,T.(2011). evidence-basedcognitiverehabilitation:Updatedreviewoftheliteraturefrom2003through2008.ArchivesofPhysicalMedicine&Rehabilitation,92,519-530.

Constantinidou,F.,Wertheimer,J.,Tsanadis,J.,Evans,C.,&Paul,D.R.(2012).Assessmentofexecutivefunctioninginbraininjury:Collaborationbetweenspeech-languagepathologyandneuropsychologyforanintegrativeneuropsychologicalperspective.BrainInjury,26(13-14),1549-1563.

Kennedy,M.R.T,&Coehlo,C.(2005).Self-regulationaftertraumaticbraininjury:Aframeworkforinterventionofmemoryandproblemsolving.SeminarsinSpeechandLanguage,26(4),242-255.

Kennedy,M.R.T,Coelho,C.,Turkstra,L.,Ylvisaker,M.,Sohlberg,M.M.,Yorkston,K.,Chiou,H,&Kan,P.(2008).Interventionforexecutivefunctionsaftertraumaticbraininjury:Asystematicreview,meta-analysisandclinicalrecommendations.NeuropsychologicalRehabilitation,18(3),257–299.

ReferencesKrasny-Pacini,Chevignard,M.,&Evans,J.(2014).GoalManagementTrainingforrehabilitationofexecutivefunctions:Asystematicreviewofeffectivenessinpatientswithacquiredbraininjury.Disability&Rehabilitation,36(2),105-116.

Leh,S.E.,Petrides,M.,&Strafella,A.P.(2010).TheneuralcircuitryofexecutivefunctionsinhealthysubjectsandParkinson’sDisease.Neuropsychopharmacology,35,70-85.

Levine,B.,Robertson,I.H.,Clare,L.,Carter,G.,Hong,J.,Wilson,B.A.,Duncan,J.,&Stuss,D.T.(2000).Rehabilitationofexecutivefunctioning:Anexperimental–clinicalvalidationofGoalManagementTraining.JournaloftheInternationalNeuropsychologicalSociety,6(3),299-312.

Mueller,J.A.,&Dollaghan,C.(2013).Asystematicreviewofassessmentsforidentifyingexecutivefunctionimpairmentinadultswithacquiredbraininjury.JournalofSpeech,Language,andHearingResearch,56(3),1051-1063.

Robertson,K.,&Schmitter-Edgecombe,M.(2015).Self-awarenessandtraumaticbraininjuryoutcome.BrainInjury,29,848-858.

Schwartz,M.F.,Segal,M.,Veramonti,T.,Ferraro,M.,&Buxbaum,L.J.(2002).TheNaturalisticActionTest:Astandardised assessmentforeverydayactionimpairment.NeuropsychologicalRehabilitation,12(4),311-339.

ReferencesSnyder,H.R.,Miyake,A.,&Hankin,B.(2015).Advancingunderstandingofexecutivefunctionimpairmentsandpsychopathology:bridgingthegapbetweenclinicalandcognitiveapproaches.FrontiersinPsychology,6,article328.

Sohlberg,M.M.,&Mateer,C.A.(2001).Cognitiverehabilitation:Anintegrativeneuropsychologicalapproach.NewYork,NY:GuilfordPress.

Tate,R.,Kennedy,M.,Ponsford,J.,Douglas,J.,Velikonja,D.,Bayley,M.,&Stergiou-Kita,M.(2014).INCOGrecommendationsformanagementofcognitionfollowingtraumaticbraininjury,PartIII:executivefunctionandself-awareness.JournalofHeadTraumaRehabilitation,29(4),338-352.

Toglia,J.,&Kirk,U.(2000).Understandingawarenessdeficitsfollowingbraininjury.Neurorehabilitation,15(1),57-70.

Vas,A.K.,Chapman,S.B.,Cook,L.G.,Elliott,A.C.,&Keebler,M.(2011).Higher-orderreasoningtrainingyearsaftertraumaticbraininjuryinadults.JournalofHeadTraumaRehabilitation,26(3),224-239.

Wise,K.,Ownsworth,T.,&Fleming,J.(2005).Convergentvalidityofself-awarenessmeasuresandtheirassociationwithemploymentoutcomeinadultsfollowingacquiredbraininjury.BrainInjury,19(10),765-775.