Executive Functions in Traumatic Brain Injury

Executive Functions in Traumatic Brain Injury Gayle DeDe, Ph.D., CCC-SLP Department of Speech, Language and Hearing Sciences University of Arizona Tucson, Arizona September 14, 2013 Objec&ves Define and describe components of execu&ve func&ons, how they relate to one another, and what their neural substrates are. Describe tests used to assess execu&ve func&ons. Describe treatments for people with execu&ve impairments. Outline Overview and defini&on of execu&ve func&ons A few words on assessment Treatment approaches Awareness Self- regula&on Mul&- tasking Func&onal Consequences of TBI TBI can cause a wide range of func&onal changes affec&ng: Cogni&on: e.g., alen&on, memory, and reasoning Sensa&on: e.g., touch, taste, and smell Language: e.g., communica&on and understanding Emo&on: e.g., depression, anxiety, aggression, and social inappropriateness Execu1ve Func1ons Impairments of execu1ve func1on are common in people with TBI Mental processes needed to use capaci&es, knowledge, and skills to engage in purposeful, goal- directed, and future- oriented behavior Frees us from over prac&ced/ formulaic responses 1

Execu1ve Func1ons Involved in covert cogni&ve and overt social behaviors Cogni&ve Behaviors Rehearsing informa&on Paying alen&on to an inservice Looking for something Social Behaviors Being appropriate Considering other people s perspec&ves before ac&ng or making a decision Delayed gra&fica&on Why the focus on execu1ve func1ons? Can affect cogni&on, language, and emo&on Return to work (Shames 2007) Reasons for termina&on (Wehman et al., 1989) Insubordina&on Poor judgment Temper outbursts Return to driving (Ortoleva et al., 2012) Neural Substrates of Execu1ve Func1ons Prefrontal Lobes: Dorsolateral, Ventromedial, Orbitofrontal, Superomedial (Anterior Cingulate), Frontal poles Execu1ve Func1on & Frontal Lobes Contusions in the frontal lobes are common. Hypoxia leads to cell death in watershed region between ACA and MCA. Figure 1, Suchy, 2009 Execu1ve Func1on and Processing Speed Processing speed affects aspects of EF. Diffuse axonal injury & hypoxia affect func&on of white maler, which leads to slowed speed of processing (e.g., Felmingham et al., 2004) What are execu1ve func1ons? 2

Unitary model of execu1ve func1ons Supervisory ALen&onal System (Norman & Shallice 1986; Shallice 2002) Automa&c Rou&nes (driving, brushing your teeth, etc) Controlled Situa&ons that involve planning & decision- making, error correc&on, novel sequencing of ac&ons, or inhibi&ng strong habitual responses Automa1c vs. Controlled Behaviors Supervisory ALen&onal System Schemas Tasks & behaviors Biasing mechanism that ac&vates/suppresses schemas Ac&va&on determined by: Environmental cues, habits Long term goals, societal norms, etc Component Models (Jurado & Rosselli 2007; Sohlberg & Mateer, 2001) ALen&onal Control: Ini&a&on and drive Response Inhibi&on Planning: Organiza&on Set Shicing & Cogni&ve Flexibility: Genera&ve Thinking Awareness Ini&a&on and Drive Individuals may have : Ø Adequate knowledge of social rules and expecta&ons Ø Adequate cogni&ve abili&es to complete a task Ø But not use these without promp&ng Laziness? Inhibi&on Act independently of internal drives and external s&muli Impairments: Persevera&on Difficulty inhibi&ng prepotent (habitual) responses Environmental Dependency Ac&ons overly determined by & bound to environment Planning & Organiza1on Organiza&on of Ac&ons => Goal Achievement Iden&fica&on Planning Time sense Impairments in: Iden&fying and Formula&ng Goals Including sub- goals Scheduling & Priori&zing Problems mul&- tasking Problems shicing sets Problems using con&ngencies 3

Planning & Organiza1on Organiza&on of Thoughts => Covert & Overt Language Use Word Finding Discourse Structure Impairments: Organiza&on of Language Word Finding Genera&ve Thinking Crea&vity, fluency, cogni&ve flexibility Generate novel ideas & perspec&ves Impairments Rigid & concrete thinking Difficulty readjus&ng plans Awareness Monitoring & Modifying behavior Incorporate environmental feedback Provides mo&va&on to adopt compensatory strategies Assessment of Execu1ve Func1ons Assessment of Execu1ve Func1ons Mueller & Dollaghan (JSLHR, 2013, p. 1051): Strong evidence concerning diagnos&c accuracy and concurrent validity of EF measures for adults with ABI is lacking. BeLer specifica&on of the construct of EF as well as research aimed at improving the quality of evidence concerning EF tests are needed. Speed of processing Verbal fluency Func&onal Measures Assessment 4

Speed of Processing Speed of processing in the Coding Subtest of the RBANS Rassovsky et al., 2006: Speed of processing significantly predicts outcomes (employability ra&ng scale & FIM) 12 months post- injury Nelson et al (2009): Speed of processing predicts performance on the Trail Making Test, Part B and Stroop Test. Interpre1ng Verbal Fluency Scores Component scores (Troyer, Moscovitch, Winocur, 1997; Troyer et al., 1998; Zakzanis, McDonald, & Troyer, 2013) Clusters Phonological or seman&c subcategories Mediated by temporal lobe Switches Tests of Execu1ve Func1ons Verbal Fluency Convergent: Given 3 items, name the category What are birds, cats, and camels? What are coffee, the sun, and flame? Divergent Seman&c: Naming animals, fruits & vegetables, etc Phonemic: Words that start with F, A, S Interpre1ng Verbal Fluency Scores People with severe TBI produce fewer words than controls on both tasks Seman&c fluency differen&ates groups beler than phonemic fluency in component scores. Transi&ons between clusters Frontal lobe Func1onal Measures Func&onal Assessment of Verbal Reasoning and Execu&ve Strategies (FAVRES) Four Tasks Planning an event Scheduling Making a decision Building a case Table 1, Zakzanis et al., 2013 FAVRES Acceptable validity, reliability, sensi&vity Total accuracy and total ra&onale correlated with employment outcome (Rietdijk, Simpson, Togher, Power, & GilleL, 2013) Four scores Accuracy, Ra&onale, Time, Reasoning 5

Func1onal Measures Voicemail Elicita&on Task (Meulenbroek, Togher, Turkstra, 2013) 4 elicita&on scenarios Convey new informa&on Request some form of ac&on Superior, subordinate, friend, colleague Stably employed and unemployed groups of people with TBI Voicemail Elicita1on Task Example: William reports to you for a project at work you are in charge of. You no&ce that he has not been following the dress code recently. The weather outside has warmed up and he started wearing shorts every other day. Call your assistant William on his office phone. Remind him of the rule that shorts are not allowed in the workplace and ask him to follow the dress code rules. Voicemail Elicita1on Task Voicemail Elicita1on Task Example response (SE Group) - Hi William. This is (First Name). - Um, it s we need to talk about the dress code here and what s allowed and what s not allowed. - Um, I m sure you know already that you can t wear, uh, shorts into work even if it s warm outside. - So if you could, uh, just remember to dress in the, uh, dress code. - If you have any ques&ons feel free to stop by and to see me or give me a call. - Thank you. Stably employed vs. unemployed groups Differed in: Informa&on giving & politeness markers Did not differ in: Ac&on requests & content mazes Data adapted from Meulenbroek et al., 2013 Treatment Trea1ng Execu1ve Func1ons Problem solving Self- regula&on scripts Awareness 6

Goal- Plan- Do- Review A Guide For Explicitly Teaching Executive Components of Tasks (Ylvisaker, 2001) Can be used with any age group Can apply to small- scale or large - scale tasks Targets problem solving & awareness Goal Management Training Levine et al. (2000) GMT group made fewer errors and responded more slowly on outcome measures Case study found improvements when a real- life task was used 308 B. Levine et al. Another approach to problem solving 300 B. Levine et al. tified in the laboratory (e.g., performance on tests of memory and attention), whereas goal neglect occurs in naturalistic situations in which behavior is not constrained by environmental Management structure or overlearned habits. Training Goal To address this need, Robertson (1996) developed Goal Management Training (GMT), a structured, interactive, What manual-based it is rehabilitation protocol based on Duncan s (1986) theory of disorganization of behavior following frontal lobe lesions. As many authors have pointed out (e.g., Miller Develop et al., 1960; Newell a mental & Simon, 1963) checking much of human behavior is controlled by goal lists, or lists of goals and subgoals rou&ne constructed in response to environmental or internal demands (e.g., get ready for guests to arrive). When the current Clearly state of affairs define does not match goals the state, a store of actions is consulted, and actions are then activated to resolve the discrepancy in an iterative process. However, actions Learn can also the be activated steps in response to accomplish to competing and sometimes irrelevant input (e.g., the letter on the bureau; see the also Norman goal & Shallice, 1986). A function of the goal list is to impose coherence on behavior by controlling the activation or inhibition of actions that promote or oppose Check progress task completion. An important aspect of goal-directed behavior is the selection of new actions when previously selected actions fail to achieve the goal. According to Duncan Fig. 1. Flowchart used to illustrate the five steps in goal management training. (1986), much of the disorganized behavior seen in patients with frontal systems dysfunction (i.e., dysfunction in the frontal cortex or its interconnections) can be attributed to Levine et al., 2000 impaired construction and use of such goal lists. rise to goal management deficits. We hypothesized that the Each of the five GMT stages corresponds to an important participants receiving GMT would show greater improvement on the posttraining tasks (relative to the pretraining aspect of goal-directed behavior (see Figure 1). In Stage 1, orienting, participants are trained to assess the current state tasks) than the participants receiving MST. of affairs and direct awareness towards relevant goals. Goals are selected in Stage 2, and these are partitioned into subgoals in Stage 3. Stage 4 concerns encoding and retention Methods of goals and subgoals. In Stage 5, the outcome of action is Research participants compared with the goal state (monitoring). In the event of a mismatch, the entire process is repeated. Training was administered along with a battery of cognitive This paper describes two applications of GMT. In Study 1, and psychosocial outcome measures 3 to 4 years post-tbi. we implemented a brief version of GMT to patients with Initial contact took place in-hospital (at the time of injury) traumatic brain injury (TBI) and impaired self-regulation within a series of 94 consecutive admissions to a major medical trauma center. Injury and acute recovery characteristics in a randomized group trial. The group trial demonstrated the potential efficacy of GMT in real-life situations using were meticulously documented in the context of a research paper-and-pencil tasks similar to many everyday activities. project on posttraumatic amnesia (Schwartz et al., 1998; Study 2 is a single-case study in which GMT was expanded Stuss et al., 1999). After exclusions due to serious medical and used to improve disorganized meal preparation behavior in a postencephalitic patient. als to participate, and loss of contact over the 3 to 4 years, illness or death, psychiatric illness, substance abuse, refus- 30 were available for participation. These patients represented the full range of TBI severity, from mild to severe STUDY 1 (with the constraint that all patients were hospitalized). Severity indicators (the Glasgow Coma Scale, GCS, and post- Because of the prevalence of goal management deficits Programs patients with TBI (Levine et that al., 1998; Mateer incorporate et al., 1987; traumatic amnesia, PTA) indicated GMT an overall moderate level Robertson et al., 1997; Whyte et al., 1996), we elected to of severity. All participants were living independently, classified as good recovery (N 5 24) or moderate disability validate GMT using TBI patients. Thirty participants were randomly assigned to receive brief trials of GMT or motor (N 5 6) according to the Glasgow Outcome Scale (Jennett skills training (MST). Before and after training, both groups &Bond,1975).Nonehadfocalneurologicalsyndromesor completed an investigation of everyday paper-and-pencil linguistic or mnestic disorders that would prevent them from tasks designed to mimic unstructured situations that give participating in the training or completing the assessment STOP! DEFINE LIST LEARN CHECK ALen&on and Problem Solving Training (MioLo, Evans, Souza de Lucia, & Scaff, 2009) Adopt a systema&c approach to iden&fying ways to solve a problem Self- monitor progress Fig. 4. K.F. s recipe checklist. Levine et al., 2000 aries, K.F. employed a strategy on 14. Within these 14, meningo-encephalitis, K.F. demonstrated neuropsychological deficits on tasks of attention, executive functioning, problems were encountered on only one (7%; see Table 6). In contrast, of the six recipes without a reported strategy, and everyday memory, deficits which corresponded to her three (50%) were associated with difficulties. impaired self-regulation in managing demands of certain everyday situations. In particular, K.F. was frustrated by her inefficiency in negotiating meal preparation. GMT is Discussion specifically designed for patients with K.F. s profile of executive dysfunction. Its flexibility allows it to be targeted This case study illustrates an application of GMT to a reallife situation. In the chronic phase of her recovery from at a variety of everyday situations. Therefore, it was readily 7

A[en1on and Problem Solving Training (Mio[o et al 2009) Goal #1: Increase insight Problem awareness, monitoring, and evalua&on: Self- monitoring sheets Educa&on about brain injury Drills to target alen&on (sustained, selec&ve, etc) A[en1on and Problem Solving Training (Mio[o et al 2009) Goal #1: Increase insight Train internal & external strategies Check mental blackboard (similar to Goal Management Training) Time management strategies, environmental modifica&on, cue cards, watch alarms A[en1on and Problem Solving Training Downloaded by [University of Arizona] at 15:49 26 June 2013 Goal #2: Learn to develop a plan STOP: THINK! Hypothe&cal and real- life situa&ons NEUROPSYCHOLOGICAL REHABILITATION OF EXECUTIVE FUNCTION 521 an associated exercise template (see Figures 1 and 2). The main aim of the group is to encourage participants to adopt a systematic approach to identifying ways of solving problems (preventing a more impulsive approach) and managing/monitoring goal achievement through development of a mental checking, goal management routine. Within the group programme, specific components of executive functioning are targeted as follows: Problem awareness (meta-cognitive processes), monitoring and evaluation. One aim of the treatment is to increase insight and awareness of how difficulties impact on everyday tasks. For this, clients and staff work on self-monitoring sheets (for recording problems as they occur in day-to-day life), receive education about the nature of the brain injury and consequences on behaviour and carry out a series of exercises simulating A[en1on and Problem Solving Training Goal #3: Ini&ate & implement plan Electronic reminders (pagers, watch alarms, etc) External memory aids Downloaded by [University of Arizona] at 15:49 26 June 2013 NEUROPSYCHOLOGICAL REHABILITATION OF EXECUTIVE FUNCTION 521 an associated exercise template (see Figures 1 and 2). The main aim of the group is to encourage participants to adopt a systematic approach to identifying ways of solving problems (preventing a more impulsive approach) and managing/monitoring goal achievement through development of a mental checking, goal management routine. Within the group programme, specific components of executive functioning are targeted as follows: Problem awareness (meta-cognitive processes), monitoring and evaluation. One aim of the treatment is to increase insight and awareness of how difficulties impact on everyday tasks. For this, clients and staff work on self-monitoring sheets (for recording problems as they occur in day-to-day life), receive education about the nature of the brain injury and consequences on behaviour and carry out a series of exercises simulating Figure 1. Attention and problem solving framework template. Miotto et al., 2009 Figure 1. Attention and problem solving framework template. Miotto et al., 2009 A[en1on and Problem Solving Training (Mio[o et al 2009) Format of Group Training: 10 weeks Weeks 1-4: Focus on ALen&on Educa&on Tasks used to demonstrate various types of alen&on Discuss internal and external strategies Week 5-10: Focus on problem solving. Given problem solving framework A[en1on and Problem Solving Training Weeks 5-10: Problem solving template Downloaded by [University of Arizona] at 15:49 26 June 2013 522 MIOTTO ET AL. Figure 2. Problem solving framework template. Miotto et al., 2009 the different types of attentional demands (sustained, selective, and divided attention). Tasks that also make demands on planning and goal management (e.g., practical forms of multiple elements tasks) are also used. In part the aim of these programme components is to develop meta-cognitive skills. Subsequently, clients are trained on specific internal and external strategies for managing attention difficulties, including using the GMT concept of checking the mental blackboard, time management strategies, environment modification, cue cards, and watch alarms. Developing a plan. A major focus within the group programme is on teaching clients to replace impulsive or inappropriate responses with more 8

A[en1on and Problem Solving Training (Mio[o et al 2009) Improvement in some measures of execu&ve func&on immediately acer treatment and 6 months later. Problem solving & Self- regula1on Scripts In general, scripts should involve (e.g., Feeney, 2010) Discrimina&on Explana&on Strategy Self- regula1on and Scripts Example: Script for staying on task (Sohlberg & Turkstra, 2011) Set cell phone alarm for 15 minutes When hear alarm, Am I doing what I am supposed to be doing? Reset alarm, and keep going. Use of Scripts Example: Ready/ Not ready script for impulsivity (Feeney, 2010) Do you have what you need to do your homework? Hierarchy of cues I am not sure you are ready because you don t have your books. Maybe get them and then will be ready. Are you ready for X? Is it &me for X now? Use of Scripts Other Scripts Flexibility/Changing your play Hard/Easy (Awareness) Choice/No choice Awareness In general, studies report an immediate increase in awareness for similar tasks (e.g., Cheng & Man 2006; Goverover et al 2007; Toglia et al 2010) Typically, studies use some form of problem solving treatment, some&mes with an educa&on component 9

Awareness Treatment: An Example (Goverover et al., 2007, also cf. Toglia et al., 2010) Par&cipants performed tasks in treatment sessions (e.g., prepare a lunch box) Before the task, the experimental group: (1) Defined goals (2) Predicted how hard the task would be (3) An&cipated and planned for errors/ obstacles (4) Choose a strategy to circumvent such difficul&es (5) How much assistance will be needed? Awareness Treatment: An Example (Goverover et al., 2007) Acer the task, the experimental group: (1) Self- assessed their performance (2) Complete a structured self- evalua&on of the task (3) Discuss par&cipants responses and the researcher described observa&ons and answers to the same ques&ons. (4) Par&cipants wrote in a journal about their experiences in performing the task Awareness Treatment: An Example (Goverover et al., 2007) Results Experimental group improved in measures of self- regula&on and organiza&on for ADLS and IADLs LiLle evidence of improvement on ecological measures (measures of general awareness and community integra&on) Awareness Treatment: Example 2 (Cheng & Man, 2006) Experimental group Concrete feedback Educa&on about TBI and resultant deficits Goal- plan- do- review Control group received conven&onal treatment Both groups showed improvements on standardized measures (FIM, IADLS) but experimental group showed greater improvements in self- awareness scores. Extras (Depending on &me) Teaching problem solving strategies Computerized training programs Mul&- tasking EF Training: Some generali&es Strategies for compensa&on Slower might be beler Trea&ng Awareness: Two Take Homes Educa&on Some version of problem solving treatment 10

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