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!