challenging behaviors: assessment and intervention strategies
DESCRIPTION
Challenging Behaviors: Assessment and Intervention Strategies. Laura A. Flashman, Ph.D., ABPP Associate Professor of Psychiatry Neuropsychiatry Section, Neuropsychology Program and Brain Imaging Laboratory, Department of Psychiatry,Dartmouth-Hitchcock Medical Center, Lebanon, NH - PowerPoint PPT PresentationTRANSCRIPT
Challenging Behaviors: Assessment and Intervention StrategiesLaura A. Flashman, Ph.D., ABPP
Associate Professor of Psychiatry
Neuropsychiatry Section, Neuropsychology Program and Brain Imaging Laboratory, Department of
Psychiatry,Dartmouth-Hitchcock Medical Center, Lebanon, NH
& New Hampshire Hospital, Concord, NH
What are “Challenging Behaviors”?
Related to Personality Changes– Impulsivity, Intrusiveness, Poor Boundaries,
Irritability, Emotional Lability, Low Frustration Tolerance
Aggression– Self injurious behavior, hurting others
What are “Challenging Behaviors”?
Related to “Deficit Syndromes”– Isolation, withdrawal, apathy, low motivation
Related to Cognitive Changes– Poor judgment, inability to comprehend
consequences, poor decision making, perseveration, impaired memory and concentration, difficulty adjusting to the unexpected
Ways to Deal with Challenging Behaviors
Medications
Behavioral Programs
Cognitive Remediation Strategies
Applied Behavioral Analysis (ABA)
Goal: To increase or decrease a particular behavior, to improve the quality of a behavior, to stop an old behavior or teach a new behavior
General Uses: Can address a broad spectrum of human behavior– Increasing productivity in the workplace– Teaching children– Precise training of military personnel– In our case, handle the challenging behaviors
associated with TBI
Seven Essential Elements of anABA-based Program (Baer, Wolf & Risely (1967)
1. Must be applied (i.e., behaviors focusing on should have some social significance).
2. Must be behavioral (i.e., environment and physical events should be recorded with precision).
3. Must be analytic (i.e., convincing evidence that the intervention is responsible for the change in behavior).
4. Must be technological (i.e., techniques could be duplicated by another).
Seven Essential Elements of anABA-based Program
5. Must be conceptually systematic (i.e., there should be relevance to established and accepted principles).
6. Must be effective (i.e., should seek to change the targeted behavior to a meaningful degree).
7. Should display some generalizability (i.e., seen in a variety of settings or to related behaviors).
Six Steps for a Solid Applied Behavioral Analysis
1. Identify Target Behaviors
2. Measure the Behavior
3. Analyze the Behavior – A B C’s
4. Develop an Intervention
5. Program Generalization of the Behavior
6. Empirically Evaluate the Results
Behavioral Terminology
Behavior – any observable and measurable act
Target Behavior – the particular behavior you have identified for change
Behavioral assessment – a description of the frequency, duration, and conditions related to a target behavior
Identification of Target Behavior(s)
Choose your battles
Start with reasonable goals (“3 shall be the number”)
Track appropriately
Once the Target Behavior is Identified…….
We need to learn all we can about this behavior
Is it a behavior we want to increase? Is it a behavior we want to replace?
– Inadequate in meeting an individual’s needs?
– Inappropriate in the current environment?
Behavior “Modification”
Modification of behavior is most effective if the motivation behind the behavior can be determined
Once motivation is known, once we understand the need that the individual is trying to meet, we can develop and teach a more appropriate replacement behavior
Available Tools of ABA
Functional Behavioral Assessment: a precise description of a behavior, its content and its consequences
Goal: Better understand the behavior and the factors that influence it
Starts with a Baseline Period – a specified time period when the frequency, duration, or intensity of the target behavior is tracked prior to the implementation of an intervention
Behavioral Terminology: The ABCs of ABA
Antecedent: the stimulus or situation to which the individual responds
Behavior: the behavior (target behavior) we see exhibited by the individual
Consequence: the stimulus or stimuli that the individual receives, or that s/he is stopped being subjected to, as a result of the behavior
Functional Behavioral Analysis
Begins as an assessment, but includes the step of systematically altering the antecedents to and consequences of the behavior to determine which are the driving forces behind the behavior
Functional Behavioral Analysis
The first step: Carefully observe and precisely describe the behavior the individual is exhibiting, and the events and stimuli in the environment both BEFORE and AFTER that behavior (i.e., Identify the ABCs)
Observe and describe the behavior across a wide sample of environments and occasions
Functional Behavioral Analysis
The second step: Look for trends in the occurrences of the behavior, for stimuli that may be evoking it, or the needs the individual is attempting to fill by exhibiting this behavior
Form hypotheses about the behavior and the function it is fulfilling
Challenge these hypotheses by systematically altering the environment to determine which are influencing the behavior
Motivations/Purposes of Challenging Behaviors
To gain attention from someone To gain a tangible consequence (a treat,
token, money, favorite video, etc). To gain a secondary consequence (to get
warmer if one is cold, colder if one is hot, to gain some sensory consequence)
To self-regulate one’s emotions (way to calm down if upset, to raise one’s arousal level if depressed)
Motivations/Purposes of Challenging Behaviors
To escape from or avoid an undesirable situation– Often in anticipation of a request to work, go to an
activity, communicate, be in an environment they find uncomfortable, loud, overstimulating, etc.
To make a comment or declaration (about one’s environment, perceptions or emotions)
To fill a habitual need, in a way that no longer works
Most Important Factor in Success of an ABA Program
CONSISTENCY
Behavioral Terminology
Discriminative Stimulus – the instruction or environmental cue to which we would like the individual to respond
Response – the skill or behavior that is the target of the instruction/cue
Reinforcing Stimulus – a reward designed to motivate the individual to respond and respond correctly
Example: I ask Cathy to get up and get ready for work in 5 minutes (DS), she does (R), and she gets to watch TV while eating breakfast (SR).
The Discriminative Stimulus
A specific environmental event or condition in response to which we would like an individual to exhibit a particular behavior (teach a person what to do when a particular thing occurs)
Goal: Help individual begin to discriminate certain stimuli from the background noise of every day life – as something important
The Discriminative Stimulus: Guidelines
Make sure you have the individual’s attention Instructions should be simple and clear;
concisely communicate only the most salient information
Be consistent in beginning stages; can be varied in many settings to encourage flexibility and generalizability as response occurs more regularly
Repetition of the instruction should be avoided (preset limits – e.g., 2 cues, 3 prompts)
The Response The response is the behavior the individual exhibits after
AND AS A RESULT OF the discriminative stimulus. If person is reacting to other stimuli, need to look at other factors (environment too distracting, person not attending?)
Be very clear about what the correct response is (“Sarah will pick up all the clothes on the floor in her room
and place them in the laundry basket within 1 minute of the request.”)
3 possible responses: Correct, Incorrect, No Response
Correct Responses are Reinforced Reinforcing Stimuli are environmental events
that occur after a behavior that increase the likelihood of that behavior occurring in the future
Treats, praise, special privileges, music, trips, almost anything can be used as reinforcement if it serves to increase the occurrences of a particular behavior (positive reinforcement)
Types of Reinforcers Primary Reinforcing Stimuli are unconditioned
– Events or rewards whose value are intrinsically realized (food, water, warmth, etc)
– Advantages: Value does not need to be taught, will not extinguish
– Disadvantages: Subject to satiation after relatively short periods of time, not representative of the natural environment
Types of Reinforcers Secondary Reinforcing Stimuli are conditioned
– Intrinsically neutral but become reinforcing through association– Can be social in origin (praise, smiles, sense of accomplishment)
or a token economy (earning tokens (e.g., money) for desirable behaviors; each one is a step towards acquisition of a primary reinforcer)
– Advantages: more convenient to use, lessens the need for proximity, more reflective of natural environments, can broaden a person’s interests, can increase length of time between presentation of reinforcers (token economy)
– Disadvantage: Need to be taught, must be maintained by repairing to primary reinforcer to reestablish interest sometimes
Types of Reinforcers Positive Reinforcement: presentation of positive
events after a particular behavior to increase the likelihood that the behavior will occur in the future
Negative Reinforcement: removal of aversive events after a particular behavior to increase the likelihood that the behavior will occur in the future (e.g., alarm goes off, you get up and shut if off, get ready for work)
Differential Reinforcement: involves reinforcing almost any positive response (successively closer approximations of the correct behavior) to some degree, but providing very strong reinforcement when the person completely exhibits the target behavior or skill
Types of Reinforcers
4 Types of Punishment
Goal: introduction of negative or removal of positive stimuli to DECREASE a particular behavior
Time out: removal of the individual from any positive stimuli (need to know motivation behind behavior. If a person screams when asked to go to work, and he gets put in time out, behavior may be encouraged, not discouraged)
4 Types of Punishment
Extinction: the withholding of a previously available consequence (reinforcer) for a response – essentially, ignoring the behavior, which results in a decrease or weakening of response rate, duration, or intensity. Behavior may increase before it decreases.
Response Cost (token economy): tokens are lost for occurrences of undesirable behavior.
Aversive Stimuli: strongly negative behavior introduced after an undesirable behavior (spanking, scolding). As a rule, to be avoided, as can do more harm than good.
Alternatives to Punishment
Goal: Reducing difficult behaviors while encouraging more appropriate behaviors
Differential reinforcement of other behaviors (DRO): reinforcement for not engaging in the target for a specified interval of time (i.e., reading not hitting)
Differential reinforcement of alternative behaviors: reinforcement of behaviors which serve as alternative behaviors to the difficult behavior (i.e., count to 10)
Differential reinforcement of incompatible behaviors: reinforcement of behaviors which are incompatible with difficult behaviors (i.e., can’t be done simultaneously)
Guidelines for Reinforcement
If the reinforcement is to be consistent and effective, the criteria for the response need to be planned out in detail, understood and used consistently by all involved in the program
Consequences for correct and incorrect responses/ behaviors should be easily distinguishable
If reinforcement is being used after correct behavior, short-lived reinforcers should be used.
Reinforcement Schedules Continuous Reinforcement Schedule: one that
provides reinforcement after every correct response. Useful for teaching of new behaviors, when goal is to emphasize relationship between DS and associated R
Partial Reinforcement Schedule: one in which only some instances of the desired response are reinforced. Often produce more responses at a faster rate than continuous schedules. Useful for maintenance of learned behaviors, for increasing the production of those behaviors once learned, and for making reinforcement more natural
Token Economies
Useful for moving from a continuous reinforcement schedule, where the individual is rewarded after each correct/appropriate response, to a schedule where the individual must make several appropriate responses before being reinforced.
Good for building the ability to delay gratification, extending an individual’s attention span, increasing the amount of work produced in a given time period
Token Economies
Provides a TANGIBLE marker of progress
Can be effective with cognitively compromised individuals
Teaching Complex Behaviors
Shaping: the process by which successively closer approximations of a behavior are reinforced. Allows reasonable goals to be set and gives an individual many chances for success on the way to learning a new behavior or extinguishing an old, inappropriate behavior
Step Analysis: breaking down of a target behavior into smaller, more manageable steps which bring a person successively closer to that target behavior
Goal: Complete the first step, get reinforced, master it, the next step becomes the new goal, etc.
Teaching Complex Behaviors Chaining: the linking of component behaviors
into more complex, composite behavior Useful for teaching those behaviors that occur in
essentially the same order each time, and is especially useful for teaching self-help skills
Task Analysis: breaking down of a behavior into its component parts/behaviors
Example: Brushing teeth, morning ADLs
Techniques Used in Behavioral Programs
Behavioral momentum: a procedure in which before asking a patient to do something he/she is unlikely to do, staff first ask him/her to perform two simple tasks he/she is likely to do
Modeling: a procedure whereby a sample of a given behavior is presented to an individual to induce that individual to engage in a similar behavior
Techniques Used in Behavioral Programs
Redirection: a procedure whereby a patient who exhibits an inappropriate behavior is prompted to engage in a more appropriate alternative behavior
Staff Assistance to Maintain Consistency
Planned conflict resolution – a designated time to channel questions, grievances, and reinforce skills with specific staff
Modeling – a procedure whereby a sample of a given behavior is presented to an individual to induce that individual to engage in a similar behavior
Generalization of the Behavior
Generalization: the application of a behavior or sill across a number of environments or to a number of related behaviors
This can be very difficulty for individuals with TBI Therefore, instructions must be designed to
change over time, in content, and in context, to help increase generalizability of program
Data Collection
3 Keys to Success with Data:
1. Make the Data Useful– Helps shape the program, assess the efficacy, look for trends in
behavior
2. Make the Data Relevant to the Goals– Must be appropriate for the behavior being documented and for
the goals associated with that behavior
3. Make the Data as Painless as Possible– Find style of data collection that works for you
Data Collection – What to track?
Frequency: How often does the behavior occur over a specific period of time?– Pd of time chosen depends on behavior being tracked– Best used when the goal for a plan is to increase or
decrease the occurrences of a behavior
– Example: Mary will decrease the number of times she approaches the nurses station from 10 to 2 times per shift.
Data Collection – What to track?
Proportion: In what percentage of available opportunities did the behavior occur?– # of target behaviors that occur in a given # of
opportunities– Best used when the goal for a plan is to increase
the quality of a behavior
– Example: Josh will increase his use of his memory book from approximately 10% of available occasions to approximately 75% of occasions.
Data Collection – What to track?
Duration: For how long did the behavior occur?– Track for open-ended behaviors that you are trying to increase – Example: Susie will increase the time she can attend during
work without a prompt from 10 seconds to 3 minutes).
– Can also be used for behaviors one is hoping to decrease or eliminate, through differential reinforcement of lesser degrees of behavior (i.e., anger management strategies – how long before he uses one effectively).
– Example: Mark will use the counting technique to calm himself when someone tells him he can’t go off the unit, reducing the length of his tantrums from 3 minutes to 30 seconds.
Data Collection – What to track?
Intensity: To what degree was the behavior present?– Can be very subjective; best if some degree of
objectivity and specificity can be accomplished– Rating Scales often used; can be developed:
» 1: Bill shows some aversion to the request but complies within 10 secs.
» 2. Bill shows significant reluctance, is arguing, and has not complied within 10 secs.
» 3: Bill attempts to leave the area.» 4: Bill knocks over a chair or throws something.» 5: Bill makes physical contact with staff or peers.
Evaluation of the Results
Feedback from those implementing plan, and the individual
Have we decreased undesirable behaviors? Have we increased desirable behaviors, or
replaced undesirable behaviors with more acceptable behaviors?
HOW MUCH less frequently, intensely? Can the individual apply these behaviors,
strategies in more than one situation?
Evaluation of the Results
Evaluate, evaluate, evaluate
Tweak, tweak, tweak
Increase reinforcement intervals
STRATEGIES FOR HELPING INDIVDUALS WITH
COGNITVE IMPAIRMENTS
Neuropsychological Testing
To provide information about cognitive strengths and weaknesses
To provide Baseline Measurements
To make recommendations for Treatment & Behavioral Management
What it is not….
Neuropsychological testing = IQ
Neuropsychological testing = Academic testing
Neuropsychological testing = Cognitive Rehabilitation
When do you refer for a neuropsychological evaluation?
When there is a question about a person’s overall level of cognitive ability
When there is a question about what role a person’s cognitive functioning has on his/her behavior
To assess for deterioration over time
To assess recovery or effectiveness of medication/treatment
To plan for cognitive remediation strategies
Potential Issues to be Addressed Safety
– Can this person be left alone?– Can this person drive?
Independence– Can this person live alone?– Can this person manage their own money?– What supports need to be provided to maximize
independent living/provide the least restrictive environment?
Potential Issues to be Addressed
Employment– Can this person work in their previous capacity?– Can this person work at all?– In what type of job would this person succeed?– What accommodations can be made to maximize
success?
Information to be gathered
Precipitating Problem – what brings them to testing? Onset and duration, etc of problem – was there a specific precipitating event? Course of problem – slow progression, fast decline, in recovery phase?
Impacting on what every day life situations?
Information to be gathered Collateral Information – from significant others,
caregivers, school when appropriate– What do they see in terms of impact, where are the
problems, what does the course look like, etc.
Also use documentation such as medical records, school records, previous test scores, vocational records, such as job evaluations, and contact with physicians
Behavioral Observations Used in Planning
Orientation Physical signs – problems with speech
(productivity, fluency, prosody, aphasic symptoms, speed), motor, gait, vision/hearing
Motivation/Task Persistence/Frustration Tolerance/Effort
Level of distractibility/ability to follow directions Fatigue/Endurance Affective Status
Cognitive Domains AssessedDuring Neuropsychological Evaluation
Attention Memory Somatosensory perception Visual-spatial functioning Language Executive function
Mood
Interpretation/Summary of Results Quantitative Data
– Appropriate Norms– Consideration of an individual’s own baseline
Qualitative Data– Boston Process Approach– Problem Solving Strategies– Testing the limits
One bad score does not a deficit make
How are Test Results Used?
Depending on the referral question, NP evaluation may:
•Provide a profile of strengths and weaknesses to guide future services.
* Confirm or clarify contributing factors to the profile.
* Document changes in functioning since prior examinations, including effects of treatment, spontaneous recovery.
How are Test Results Used?
*Clarify what compensatory strategies would help.
* Suggest possible interventions.
* Result in referrals to other specialists.
NP Deficits in TBI Acute (or time limited) NP difficulties
– Arousal, alertness, orientation– Post-traumatic amnesia – Aphasia and neglect
Chronic (long-term) Impairments– Attention– Memory– Executive functioning, concept formation, planning,
information processing speed
Overview: NP Deficits in TBI
Influenced by factors such as:–Type (penetrating or closed, focal or
diffuse)–Severity of injury–Site of injury–Length of time since injury–Age–Premorbid level of functioning
Common Cognitive Deficits following TBI
Slowed speed of information processing
Attention– Sustained attention– Attention span– Divided attention– Multiple processing
Common Cognitive Deficits
“Executive Functions”– Reasoning– Problem solving– Self-monitoring– Emotional and behavioral control/ modulation– Insight and judgment
Memory – Working memory– Short-term and long-term memory
Cognitive Deficits after TBI While cognitive deficits have been reported in all
domains, deficits in attention/concentration, memory, and executive function are the most common following TBI due to their diffuse nature
There is also significant variability due to more focal injury. Frontal and temporal lobes are most vulnerable.
Deficits generally improve over time, although persistent deficits are seen after more severe injuries, and even after mild TBI (PCS)
Deficits resulting from TBI Changes in personality are frequent
due to frontal lobe injury, and can additionally impact on cognition
Cognitive and personality changes can result in difficulties in interpersonal relationships, maintaining jobs, and may lead to legal difficulties
Cognitive Remediation: What is it?
A group of strategies intended to help persons with cognitive dysfunction to improve cognitive, perceptual, psychomotor and behavioral skills.
GOAL: To improve the individual's ability to function in work, academic, and community living environments.
SKILLS-TRAINING MODELRestorative Model
Views the brain as “plastic”
Practicing a task that requires a particular cognitive skill results in improvement and allows the individual to generalize the learned skill to similar tasks or tests of cognitive functioning
Individual learns cognitive skills by performing a variety of tasks
SKILLS-TRAINING MODELRestorative Model
Shows some utility in treatment of more basic or fundamental abilities such as attention, concentration, and mental speed
Problem: lack of generalizability between tasks performed in treatment and the expression of the skill in daily life
STRATEGY SUBSTITUTION MODEL: Compensatory Model
Presence of impairment is taken as a given and the individual is taught how to perform specific functions in a new way, taking into account the individual’s strengths and weaknesses
Focus on facilitating the return of functional activities by substituting an impaired function of a more intact ability
STRATEGY SUBSTITUTION MODEL: Compensatory Model
Helps individual to anticipate how their deficit may effect their functioning and develop strategies to compensate for them.
Requires adequate awareness of deficits on the individual’s part in order to be effective
Cognitive Remediation
Cognitive remediation or rehabilitation at any level (acute or community re-entry) is the teaching of compensating strategies to either develop or augment skills that the individual needs to experience an independent meaningful life.
Cognitive Remediation
Cognitive Rehabilitation is all about CONTROL.
- Gives the person the skills and choices to develop control in their life!
- Important to develop this control in the shortest amount of time possible
Use of cognitive strategies is a LIFE LONG commitment!
Cognitive Remediation
Competency equals the development of appropriate cognitive strategies
Part of the task of Cognitive Rehabilitation is developing a “New Normal” and leading that person towards acceptance. This involves attention to both cognitive issues and emotional/ psychiatric issues
Development of Compensatory Strategies
Adjustment to the use of these strategies requires family involvement and a change in the families expectation and messages that it send to the individual
Compensatory strategies are specific to a task, place or function
Important Items To Keep In Mind
Compensatory strategies typically involves one or more of the following:1. Change in the task2. Change in the environment3. Change in how the person performs the task4. Use of some type of prosthetic device
Determining What Areas to Focus On
Assess and identify the individual’s deficit areas with regard to cognitive, behavioral, social and language dysfunction
Determine the individual’s strengths and weaknesses
Inventory individual’s perceptions as to which areas are causing them the greatest personal distress
Determining What Areas to Focus On
Talk to supportive personnel (family, friends, staff), obtain their input on areas the individual struggles with
Prioritize those deficit areas that are having a GLOBAL affect on the person’s daily lifestyle
Establish goals for the most fundamental skill first
Recommendations toward the Successful Training/Utilization of Compensatory Strategies
Engage the individual in strategy selection
Chose goals that are concrete and functional in nature
Use tasks relevant to the persons life to remediate functions. Use real life tasks that are relevant to the person
Recommendations toward the Successful Training/Utilization of Compensatory Strategies
Consider the individual’s personal history, personality, premorbid status and current level of functioning. If the strategy is too difficult, culturally inappropriate, demeaning etc. you are doomed to failure
Be creative and flexible
Recommendations toward the Successful Training/Utilization of Compensatory Strategies Make learning the strategy fun, personal and
thereby motivating. Incorporate, when possible, the person’s interests
Translate what the individual should do into what they want to do
Look at each client as an individual. Don’t mass produce strategies and expect them to fit every client
Recommendations toward the Successful Training/Utilization of Compensatory Strategies
Initially, allow the person to fail before intervening
When intervening provide the least assistance possible to identify where the task brakes down
Recommendations toward the Successful Training/Utilization of Compensatory Strategies
As the person is performing the task, ask what they are thinking
Do they know there is a problem and what it is?
Do they know what to do next but can’t figure out how?
Factors Effecting an Individual’s Ability to Utilize Cognitive Strategies
Level of awareness Level of acceptance Emotional status Level of motivation Family/ social support
Components of Attention
Arousal Sustained Attention/ Concentration Working Memory Selective Attention Alternating Attention Divided Attention
Primary Treatment Strategies
Pacing:
Regulate the amount of energy the person expends doing a task. Avoid fatigue
Schedule tasks requiring attention at time when the individual has the most energy
Schedule rest periods and breaks
Primary Treatment Strategies
Regulate the flow/ speed of information Regulate the amount of information Reduce sources of stimulation/ distractions Talk out loud to self/ verbal labels Write down brief list of what to attend
Primary Treatment Strategies
Do one thing at a time. Ask people to wait until you finish what you are doing.
Increase variety Allow a realistic time frame for
completion of task Visual or auditory cues
Primary Treatment Strategies
Change the task. Break down tasks into components. Do each component independently.
Audio tape lectures etc.
Formal Attention Training
Components of Memory
Explicit (declarative) vs. Implicit (Procedural) Memory
Encoding, Storage (Consolidation), Retrieval Processes
Old (Remote) vs. Recent Memories
Auditory vs. Visual Modalities
Primary Treatment Strategies Memory
Maximize (train) attention
Reduce environmental distractions
Downgrade memory demands- Amount of material to be remembered- Periods of delay between presentation
of info. and recall- Simplify information
Primary Treatment Strategies Memory
Organize/ Categorize information Translate into your own words Relate something new to something familiar Break down info into small pieces Multi-sensory input Provide opportunity for repetition. Rehearse
during the first hour after the event
Primary Treatment Strategies Memory
Practice output Provide verbal reminders/ written prompts Develop a set routine/ procedure A picture is worth a thousand words Develop a memory organizer Use Lo-Tech Devices: Beeper, watches,
reorders Chart progress
MEMORY STRATEGIES VERBAL MNEMONICS
Word Mnemonic – Each letter cues recall of an idea Social Pragmatics (LISTEN)
(L)ook at the person(I)nterest yourself in the conversation(S)peak less then ½ the time(T)ry not to interrupt or change the topic(E)valuate what is said(N)otice body language
MEMORY STRATEGIES VERBAL MNEMONICS
Sentence Mnemonic – First letter of each word cues a specific memory or sequence of idea(A)ll (G)ood (B)oys (D)eserve (F)avor
Rhymes – Sing song reminderI before E except after C. Not for sounds like “AHY” as in neighbor or weigh
Memory Organizer System
Purpose: Make ones life easier, less stressful. Promotes success and acts as a safety net.
Who needs it: people with
1. Memory problems
2. Difficulty with organization
Memory Organizer System
Form: varies dependent upon sensory, physical, cognitive and emotional limitations.
Need to take into account personal preferences and lifestyles
Commercially available or home made.Electronic or paper.
Memory Organizer System
MEMORY/CONTENT
Prospective memory: to do list Phone numbers/ addresses Calendar appointment Log of daily events Project or task information Graphs or tables of accomplishments Lists of strategies to use
Memory Organizer System
ORGANIZATION/CONTENT
Steps for carrying out routine/ frequent tasks Steps for carrying out infrequent tasks Plan of how blocks of time are to be allocated to
tasks during the week. Overview of how to approach a problem/ decision Flow diagram of things/ steps to do in a project
Memory Organizer System
FEATURES Personal style & Comfort (e.g.
professional look vs. school notebook) Lose-leaf (with indexed sections) Size Presentation (2 pgs. = 1 wk., 1 day or
2 days) Shop before buying
Memory Organizer System
FORMAT List - To do lists Table - 1 or 2 daily routine activities (i.e.
meds) Outline - Organizing simple tasks only Boxes & Flow Diagrams - Organize
sequences or steps of complex tasks. Good for problem solving situations which require decision making
Memory Organizer System
Combining Lists & Box-Flow Diagrams
Schedule Remembering appointments Organizing one’s time
Memory Organizer System Implementing a Memory Organizer
-Only one system-Set up Section(s): at least List and
Calendar-Learn how to use organizer
training: rote learning, role playing-Remembering to remember: regular time & review times-Locating memory organizer: routine place-Revise/ update system as needs change
Components of Executive Functions
Problem Identification/ Preparation Goal Formulation/ Hypothesis Generation Planning Organization Initiation Self-Regulation/ Self-Monitoring
(sequencing, error recognition and correction, follow-through
Primary Treatment Strategies: Executive Functions
Maximize (train) attention Choose less complex versions of the activity Break down task into components Simplify task. Condense or eliminate non-vital
steps. Reintroduce once learned. Provide clear, simple instructions that impart
a structure for the performance of the task
Primary Treatment Strategies: Executive Functions
Organize/ planningUse flow diagrams or outline
Initiation-Educate the individual and family as to the nature of the problem-Develop schedules. -Forward and backward chaining-Consistency-Lo-tech devices (beepers, watches)
Role Play
Executive Functions: Problem Solving/ Decision Making
Problem SolvingSOLVE Mnemonic
(S)pecify the problem – Define it(O)ptions – What are they?(L)isten to other’s opinions and advice(V)alue Clarification – Is the problem worth
solving?(E)valuate and Recycle – Was the problem
solved?
Summary
Many types of challenging behaviors can result from TBI
Different types of problems require different types of interventions
Driven by the needs/wants of the individual AND their capabilities
Creative thinking, knowing and listening to the person, and being willing to modify strategies lead to greatest successes
Summary
Not every strategy will work in every situation
Be a diligent observer (ABCs) Plans/interventions will need to be
modified over time These things can really work, and can
really help increase quality of life!