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Challenging

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					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

    & 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

              Can address a broad spectrum
 General Uses:
 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 an
ABA-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 an
         ABA-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

         Behavior – the particular behavior
   Target
   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

   Startwith 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”

                 behavior is most effective if
  Modification of
  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

 Thefirst 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 anddescribe 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)
Types of Reinforcers

 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
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

 Ifthe 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
 Ifreinforcement 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
           moving from a continuous reinforcement
 Useful for
 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

      be effective with cognitively
   Can
   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: aprocedure 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: theapplication 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

   Tomake 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

   assess recovery or effectiveness of
 To
 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 usedocumentation 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 Assessed
During 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
 Whilecognitive 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 MODEL
Restorative 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 MODEL
Restorative 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 task
   2. Change in the environment
   3. Change in how the person performs
   the task
   4. 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 reminder
   I 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/ planning
    Use 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 Solving
SOLVE 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!