Challenges Post ABI
- recognizing problems as they arise,
- analyzing information,
- decreased flexibility in thinking , impulsivity in decision making
- Issues switching attention easily;
- Difficulty accessing previously or recently stored information;
- Decreased ability to organize and execute plans that have been made.
Executive functions refer to higher-level cognitive functions that are primarily mediated by the frontal lobes. These functions include insight, awareness, judgment, planning, organization, problem solving, multi-tasking and working memory (Lezak, 1983). Disorders of executive functions within the ABI population have been found to be heterogenous (Kennedy et al., 2008). For those who sustain an ABI, generating active solutions to problems encountered is itself a problem. Many show difficutly in identifying realistic goals, establishing priorities and time frames, weighing the pros and cons of a solution.
Goals of Treatment
- Improve ability to consider multiple solutions, perspectives
- Encourage systematic approach to problem solving
- Improve an individual’s ability to change their focus
- Improve organization, planning, initiation and impulse control
- Define the problem;
- Develop a list of possible solutions and the pros and cons of each;
- Evaluate the success of each solution and be willing to try again;
- Targeting goal setting, planning, initiation, monitoring, time management and impulse control (CASLPO 2002).
Materials and Devices
- Didactic educational instruction
- Specialized computer software
- Reading and homework activities
- Mindfulness training
- Paging systems
Treatment to Improve Reasoning, Problem Solving and Executive Functions
Enhancing Executive Function
Chen et al. (2011) in a recent study, randomized a group of individuals (n=24) who had sustained an ABI, into one of two groups: a goals training group (n=12) and an education group (n=12). The goals training program (the experimental condition) was based on a management training program. Participants attended ten 2-hour sessions of group based training, 3 individual 1-hour training sessions and 20 hours of home practice over 5 weeks. The control group attended a five week didactic educational instruction regarding brain injury. Following training, performance on tests of attention and executive control increased for 100% of participants in the experimental condition, while only 58% in the education groups showed an increase in test scores. Learning and memory performance scores increased for 92% (11/12) of those in the goals training program and 33% (4/12) in the education program.
In a RCT conducted by Vas et al. (2011), 28 individuals who had sustained an ABI and were at least 2 years post injury, were assigned to one of two groups: the Strategic Memory and Reasoning Training (SMART) group or the Brain Health Workshop (BHW) group. Each group received 15 hours of training over an eight week period. Those in the SMART group were given information about brain injuries, were asked to read pieces of literature on brain injury and were given homework assignments to be completed for the next meeting. The SMART sessions were built around three strategies: strategic attention, integration (combining important facts to form higher order abstracted meaning) and innovation (derive multiple abstract interpretations). Those in the BHW group participated in information sessions. Sessions for the BHW groups included an introduction to brain anatomy, functions of the brain, neuroplasticity, and the effects of lifestyle on the brain (diets, exercises and cognitive changes following a ABI). Study results indicate that those assigned to the SMART group showed significant improvement on gist reasoning and measures of executive function.
Rath et al. (2003) completed an RCT comparing two cognitive rehabilitation therapies: conventional (cognitive remediation and psychosocial components) versus an innovative rehabilitation approach focusing on emotional self-regulation and clear thinking. Outcomes were measured across multiple domains of cognition including attention, memory, reasoning, psychosocial functioning, and problem solving measures. Significant changes comparing baseline to post intervention outcomes were seen for each group, however, the improvements were different for the interventions. Those in the innovative groups showed significant improvement in problem solving, problem solving self appraisal, self appraised clear thinking and emotional self-regulation and improvement on the visual memory immediate recall assessment and the self-esteem assessment. Those in the conventional group improved on test reasoning, endorsed less severe somatic symptoms. Emotional self regulation also improved.
In a currentRCT Novakovic-Agopian et al. (2011) randomly assigned 16 individuals to either a goals training (goals-edu) group or an educational instruction (edu-goals) group. The goals training program had 2 components: the first emphasized mindfulness-based attention-regulation training, and the second emphasized patients defined goals. Training involved ten 2-hour sessions of group training, 3 individual 1-hour session and 20 hours of home practice over a 5 week period. An example of training included the implementing a calendar or organizational system to increase completion of assignments or tasks. At the end of the five week period the groups reversed rolls. Both groups were assessed at baseline, at the end of the first 5 weeks, and again at the end of the 10th week. Those in the goals-edu group showed significant improvement on the attention and executive function summary domain compared to the edu-goals group. At the 10th week evaluation time period, the edu-goals group, once they had completed the training sessions, also showed improvement and the goals-edu group continued to show improvement despite no longer receiving the intervention (Novakovic-Agopian et al., 2011).
In an earlier RCT,Ownsworth et al. (2008) randomly assigned individuals to one of three groups: Group 1: group based support, Group 2: individual occupation support, Group 3: combined group and individual support interventions. All were evaluated pre- and post-intervention then again at the seven -month follow up. Overall, when looking at the baseline measures, they found no significant differences on the performance self-ratings, satisfaction self-ratings, relatives’ performance ratings, and relatives’ satisfaction ratings (p>0.05) for the groups. The satisfaction self-ratings between pre and post assessment, indicated an improvement after each intervention (individual p<0.001; group p<0.025; combined p<0.01). At follow-up, an improvement in self-rated satisfaction was noted for the group and combined interventions only (p<0.01). Results from the Canadian Occupational Performance Measure (CPOM) indicate that there were no significant differences when looking at the scores from the group intervention pre-to post-comparison. Significant improvement was noted when looking at the scores for the individual and combined interventions (p<0.01 and p<0.025 respectively). Pre-assessment and follow-up assessment for the relatives’ ratings of performance was significant for all three interventions (individual p<0.01; group p<0.01; combined p<0.025). Relatives’ ratings of satisfaction (pre and post) found a significant improvement for the individual (p<0.025) and combined (p<0.01) interventions but not for the group intervention (p<0.117). A look at the psychosocial outcomes for each intervention group showed few significant differences.
Goal Management Training versus Motor Skills Training
Levine et al. (2000) completed a RCT comparing a group of patients using goal management training strategies to a control group who were exposed to only motor skills training. The treatment group improved on everyday paper and pencil tasks as well as meal preparation, which the authors used as an example of a task heavily reliant on self-regulation.
The reader is encouraged to review the aforementioned studies within Table 7.5 at the end of this module for further details
There is Level 1b evidence to suggest sort term intensive training benefits gist-reasoning which benefits executive function post TBI (Vas et al., 2001).
There is Level 2 evidence from one study to suggest group treatment of problem solving deficits is effective in improving executive function, problem solving self-appraisal and self-appraised emotional self-regulation (Rath et al., 2003).
Based on the findings from Chen et al. (2011), there is Level 2 evidence suggesting a goals training group is effective in improving attention and executive control.
There is conflicting evidence supporting the use of group-based interventions to treat executive dysfunction post ABI(Novakovic-Agopian et al.,2011; Parente et al., 1999; Ownsworth et al., 2008).
There is Level 2 evidence, based on a single RCT conducted by Levine et al. (2000), that goal management training is effective for improving paper and pencil everyday tasks and meal preparation skills for persons with an ABI.
Group cognitive initiatives appear to be successful in improving attention and executive control post ABI.
Goal management training is effective for treating some executive function deficits.