The Executive Function Task Application Model (EFTAM): development and application

The Executive Function Task Application Model (EFTAM): development and application Charlie Chung 1, Alex Pollock 2, Tanya Campbell 3, Brian Durward 4 1 Occupational Therapy, NHS Fife, Dunfermline 2 Nursing Midwifery and Allied Health Professions Research Unit, Glasgow 3 Occupational Rehabilitation Services, Stirling 4 NHS Education Scotland, Edinburgh Correspondence: charliechung@nhs.net

The model was developed from the literature review of a PhD thesis Executive Function after Stroke: Implications for Rehabilitation of Activities of Daily Living

This presentation will cover: Background Executive function definition Neuropsychology and occupational therapy theories which informed model development The Executive Function Task Application Model Case examples Intervention possibilities

Background Following stroke, up to 75% of patients will experience impairment of executive function (Riepe et al. 2003) Executive dysfunction may limit rehabilitation potential. Existing assessment methods cannot determine how executive function is being applied to reallife tasks.

Executive Function refers to a set of skills or processes required for effective problem-solving, planning and organisation, selfmonitoring, initiation, error correction and behavioural regulation (Evans 2003) p. 53

The neuropsychology behind the Executive Function Task Application Model (EFTAM)

Executive Function 5 components

Executive Function Parallel Systems (Sohlberg et. al 1993)

Executive function is required for tasks which: Are novel Are complex Are difficult Are dangerous Require error correction (Gazzaniga 2002)

Task Performance Theory

Task Concept There are five stages to the aspect of client engagement which are essential for productive action. These are: 1) Task selection, where the individual makes the decision to engage in the activity. 2) Task execution, where the individual undertakes the process of the activity. 3) Task completion, where the individual is aware that the end of the activity has been reached. 4) Task evaluation, where the individual can evaluate the quality of the activity outcome. 5) Task satisfaction, where the individual can achieve a positive emotional response from the activity engagement. (du Toit 1991)

The Executive Function Task Application Model

Upper body dressing task with verbalisation of reasoning CASE EXAMPLES

MARY Mary is an 86 year old female who experienced a right hemisphere stroke which resulted in a left sided weakness. Her performance was characterised by: Difficulty verbalising reasoning short two and three word answers Unable to move from one part of the task to the next Required assistance to put on a cardigan Expressed satisfaction with the dressing process

Mary EFTAM profile

JANET Janet is a 76 year old female with a right hemisphere stroke resulting in severe left sided weakness. Her performance was characterised by: Able to verbalise a detailed account of her dressing procedure. Unable to solve the problem when her cardigan became caught under her weak arm. Able to verbalise that she was aware of the problem. Unable to identify the source of the problem and required assistance Expressed dissatisfaction with the dressing process

Janet EFTAM profile

Executive Function Training INTERVENTION EXAMPLES

Executive function training Task selection Salience and external inhibition of rules (Amos 2002) Self Awareness training - condition education, self monitoring and judgment training, concrete feedback, goal setting exercises (Cheng 2006; Goverover 2007) Verbalisation, chunking and pacing for information processing (Dirette 1999)

Executive function training Planning Pre-planning for anticipated obstacles (Goverover 2007) Autobiographical episodic memory cueing procedure (Hewitt 2007) Goal Management Training steps 3 and 4 list the steps and learn the steps (Levine 2000) Problem solving training - alternative strategy decision making (von Cramon 1991)

Executive function training Execution Group treatment for problem solving recognising cognitive distortions, misattributes and illogical thinking role play (Rath 2003) Multifaceted treatment of executive dysfunction - initiation, execution and regulation training (Spikman 2010)

Executive function training Evaluation Video Feedback (Schmidt 2013)

Key take home messages: 1. Avoid focussing only on repetitive practice 2. Verbalising thought processes can provide a means in which to create EFTAM profiles. 3. Allow time during intervention for adequate awareness training, planning, evaluation and reflection 4. As a team, consider using an executive function intervention for appropriate patients.

References Amos, A. 2002, "Remediating deficits of switching attention in patients with acquired brain injury", Brain Injury, vol. 16, no. 5, pp. 407-413. Cheng, S. K. W. & Man, D. W. K. 2006, "Management of impaired self-awareness in persons with traumatic brain injury", Brain Injury, vol. 20, no. 6, pp. 621-628. Dirette, D. K., Hinojosa, J., & Carnevale, G. J. 1999, "Comparison of remedial and compensatory interventions for adults with acquired brain injuries", Journal of Head Trauma Rehabilitation, vol. 14, no. 6, pp. 595-601. du Toit, H. 1991, Patient Volition and Action in Occupational Therapy IN Occupational Therapy in Psychiatry and Mental Health, Fourth edn, Whurr, London and Philadelphia. Evans, J. J. 2003, "Rehabilitation of Executive Deficits," in Neuropsychological Rehabilitation: Theory and Practice, B. A. Wilson, ed., Psychology Press, pp. 53-70. Gazzaniga, M. S., Ivry, R. B., & Mangun, G. R. 2002, "Executive Functions and Frontal Lobes," in Cognitive Neuroscience, Second edn, Norton, pp. 499-536.

References Goverover, Y., Johnston, M. V., Toglia, J., & Deluca, J. 2007, "Treatment to improve self-awareness in persons with acquired brain injury", Brain Injury: [BI], vol. 21, no. 9, pp. 913-923. Hewitt, J., Evans, J. J., & Dritschel, B. Theory driven rehabilitation of executive functioning: Improving planning skills in people with traumatic brain injury through the use of an autobiographical episodic memory cueing procedure. [References]. Neuropsychologia 44[8], 1468-1474. 2006. Levine, B., Robertson, I. H., Clare, L., Carter, G., Hong, J., Wilson, B. A., Duncan, J., & Stuss, D. T. 2000, "Rehabilitation of executive functioning: an experimental-clinical validation of goal management training", Journal of the International Neuropsychological Society, vol. 6, no. 3, pp. 299-312. Rath, J. F., Simon, D., Langenbahn, D. M., Sherr, R. L., & Diller, L. 2003, "Group treatment of problem-solving deficits in outpatients with traumatic brain injury: A randomised outcome study", Neuropsychological Rehabilitation, vol. 13, no. 4, pp. 461-488. Riepe, M. W., Riss, S., Bittner, D., & Huber, R. 2003, "Screening for cognitive impairment in patients with acute stroke. [References]", Dementia and Geriatric Cognitive Disorders, vol. 17, no. 1-2, pp. 49-53.

References Schmidt, J., Fleming, J., Ownsworth, T., & Lannin, N. A. 2013, "Video feedback on functional task performance improves self-awareness after traumatic brain injury: a randomized controlled trial", Neurorehabilitation and Neural Repair, vol. 27, no. 4, pp. 316-324. Sohlberg, M. M., Mateer, C. A., & Stuss, D. T. 1993, "Contemporary approaches to the management of executive control dysfunction", Journal of Head Trauma Rehabilitation, vol. 8, no. 1, pp. 45-58. Spikman, J. M., Boelen, D. H. E., Lamberts, K. F., Brouwer, W. H., & Fasotti, L. 2010, "Effects of a multifaceted treatment program for executive dysfunction after acquired brain injury on indications of executive functioning in daily life", Journal of the International Neuropsychological Society, vol. 16, no. 1, pp. 118-129. von Cramon, D. Y., Matthes-von Cramon, G., & Mai, N. 1991, "Problem Solving Deficits in Brain Injured Patients: a Therapeutic Approach", Neuropsychol Rehabil, vol. 1, pp. 45-64.