Executive Function Module 4 Flashcards
What is Executive Function?
When is it developed?
It is the cognitive functions needed to plan an activity, problem solve the issues that arise, and determine when the activity is completed.
**It is the latest to develop in our development and there is a lot of overlap between all sub components
What is Metacognition?
The cognitive functions needed to determine how well your plan went and what needs to be changed in the future to improve performance
**Basically reflecting on how to do things
List the components of Executive Function?
- Self-awareness
- Goal setting
- Planning
- Initiation
- Problem Solving
- Self-monitoring
What is “Self-Awareness”
-Goal directed intentions
“I want to bring something to the party that everyone will enjoy”
-Appreciation of strengths and weaknesses
“I am not good at cooking but I am a great baker”
-Recognition of oneself within a social context
“I am the quiet person in the corner who tends to help with setting things up”
What factors affect your actions and responses
“I tend to be a people pleaser so whatever I am asked to bring I tend to bring”
What is “Goal Setting”
-Identifying elements of a problem
“I’d like to make my famous cheesecake brownies but they take a long time”
-Identifying criteria for solutions
“I need something with fewer steps or pre-made”
-Recognizing potential constraints to solutions
“I have a meeting in the afternoon so I will need to shop and cook before the meeting”
-Comparing problems to previous solutions
“Last time I had to get a last minute treat I bought that ice cake from ShopRite that everyone seemed to love”
(have you experienced a similar issue in the past? what did you do? Did it work?)
What is “Planning”
-Organizing thoughts and actions
“First shopping then go home to cook then go to work”
-Ability to control impulses
“These chips look goof but it isn’t what im here for”
-Awareness of appropriate planning sequences
“I need to know what ingredients I need before I go to the store”
-Deciding about locations and time frames
“Ill go to shoprite at 9:30 am and be back home by 9:45”
-Choosing necessary materials to achieve goals
“I am going to make the cheesecake and here are the ingredients”
- Predicting Outcomes
- Tracking Progress
- Evaluating Solutions
What is “Initiation”
-Ability to persevere
“I want to text my friends about the party, but I have to get shopping done first”
- Mental flexibility (change things around as needed)
- Behavioral flexibility (being able to substitute one component for another)
- Ability to complete actions within a time frame
- Ability to avoid premature actions (impulse control)
- Ability to follow rules (with mental flexibility)
What is “Self-Monitoring”
- Ability to make good judgements
- insight
- social sensitivity (awareness of rules and structures as they apply to social structures)
- self-inhibition (impulse control)
- Self-evaluation (did I do well/not well?)
EF assessments -
“Simulated Tasks and Self-Report”
-Name each one
- Behavioral Assessment of Dysexecutive Syndrome (BADS) - Simulated Task Performance
- Behavioral Rating Inventory of Executive Function (BRIEF) - Frequently used in school system (Observation/Self-report)
- Dysexecutive Questionnaire - (part of the BADS) (Self-Report)
Behavioral Assessment of Dysexecutive Syndrome (BADS)
- Simulated Task Performance & Self-Report Questionnaire
- A test kit that is largely paper and pencil
- Completed in a quiet clinic environment which does not approximate the EF needs posed by complex real life environments
Time: 40 minutes (extensive time to score)
Dysexecutive Questionnaire
Two scales completed:
- Self-report
- Caregiver Report
- Part of the BADS system but often given as a stand-alone assessment
-20 questions that focus on difficulties experienced in everyday tasks
Time: 10 minutes
Behavioral Rating Inventory of Executive Functions (BRIEF)
- Several Versions: Self Report and Caregiver/Teacher Report
- at home and at school
- examines EF, attention, & memory
- *For CHILDREN
BADS - Modified Six Elements Test
- Client has 10 minutes to do 6 sub-tasks
- client needs to try all of them within the time limit
- Six Elements sometimes given alone as the most predictive subtest
- Requires planning, task switching, and processing speed
Executive Function Assessment - Functional Task Performance
-Name each one
- Executive Function Route Finding Task
- Multiple Errands Test
- MET-Hospital Version
- Executive Function Performance Test (EFPT)
- Kettle Test
- Hotel Task
Executive Function Route Finding Task
**Oldest Test
- real life functional performance
- client is asked to find a given location as quickly and efficiently as possible (How do you get to the student center?)
- Therapist scores client’s performance in terms of PLANNING (this isn’t about motor performance, vision, etc.)
**How did you plan to find your route in a 3D spatial environment
Time: ~10 minutes
**This is a DYNAMIC assessment = therapist provides cues to see if route finding performance improves. Standardized scoring used to assess performance and cue use.
Multiple Errands Test (MET)
- Client is instructed to complete several activities (errands) which include buying items, gathering information, and interacting with others to complete the activities
- Route finding is part of this test (scored on moving through locations most efficiently)
- Specific to location of assessment
Scoring:
- Inefficiencies - where a more effective strategy could have been used
- Rule breaks - if any one of the given task rules or social/pragmatic rule was broken
- Interpretation failure - errands were misunderstood
- Task failures - one of the 12 errands not completed
**more complex than route finding and also more ecologically valid for common everyday problems
MET - Hospital Version
specific to hospital, similar tasks as MET
Executive Functional Performance Test (EFPT)
Actual Task Performance in Constrained Environment
- Hand-washing - used as a screening to determine if client can participate in the assessment
- oatmeal preparation
- telephone use
- taking medication
- paying bills
Time: ~45 minutes
Cost: Free (OT assembles supplies)
Scoring:
Cues needed - include rating of what type of cue needed
EF skills assessed
- Initiation
- Execution
- Completion
Kettle Test
Actual Task Performance in Constrained Environment
Only assesses performance in one specific KITCHEN task, given over-familiarity with this task may not represent client functioning in other tasks
Scoring: errors and performance
0=intact performance
4 = physical demonstration or assistance
Hotel Task
Functional Task in Constraint Environment (functional version of the Modified Six Elements test from BADS)
- Pretend you work at a hotel front desk
- 6 functional Tasks
-individual is given 15 minutes to complete assessment
FOR: Dynamic Interactional Approach (DIA)
What is the focus on?
What are the components?
It is an OCCUPATION FOCUSED approach
PERSON
- current stage of life, emotional/motivational factors that influence treatment
- Client’s current AWARENESS of performance and abilities
OCCUPATION
-Generalizability and potential for transfer of skills
ENVIRONMENT
-Focus on zone of proximal development (match between abilities and what the environment provides/requires
DIA Treatment Focus
- Main cognitive areas
- Treatment Focus
Main areas of cognitive functions:
- Meta-cognition
- Awareness
- Monitoring
- Planning
- Ability to generalize
Focus: Occupation Based Activities
- use dynamic occupations as primary method of treatment delivery
- therapist must systematically develop upgrades/downgrades to each activity
- Have client participate in selecting the occupations (COPM –> select from valued occupations checklist or just have client say let’s work on “this” and “not that” today)
Generalization DIA
Teach strategy (self compensatory approach)
- select one strategy to use (self-instruction, self-questioning)
- Have the client practice using the strategy in a number of different occupations
- generalization occurs as the client tries the same technique in multiple different environments with different needs
Make Modifications (environmental compensatory approach) -for a selected occupation modify the task so client can be more successful using the strategy
Why choose DIA approach?
What is the goal?
- Client lacks awareness and insight into deficits and you want to improve it
- client has executive impairments
- client has enough basic cognitive functions (memory, attention, etc.) to work on higher level problem solving
GOAL: develop new strategies that the client can use for information processing
Formal Assessments in DIA
Any test that allows you to observe the explicit effects of cueing on performance
- Contextual Memory Test
- Toglia Category Assessment (EF)
- Deductive Reasoning Test (EF)
- Dynamic Object Search Task (VP)
- Executive Function Performance Test (EFPT)
- Route Finding Test
- *- Prospective/Retrospective Memory Questionnaire (because you can examine the effect of self vs environmental cueing)
FOR: Cognitive Orientation to Daily Occupational Performance (CO-OP)
Client Selected Goals
Client Selected Goals
- they identify problem areas
- they identify activity based goals
- goals designed to maximize engagement
CO-OP: Dynamic Performance Analysis (DPA)
Dynamic Performance Analysis (DPA)
- therapist observes client performance of selected activities
- therapist identifies “breakdowns” in task performance, where cues or assistance are needed
- Therapist observation often leads to changes in client goals
CO-OP: Cognitive Strategy Training
“Goal-Plan-Do-Check” metacognitive strategy is taught to the client
- helps client develop a plan to improve performance in daily activities
- develop a method for evaluating the activity (Knowledge of results and knowledge of performance )
CO-OP: Guided Discovery
Therapist assists with self-monitoring, error awareness, and self-instruction of performance
-client is helped to learn about their performance, use the metacognitive strategy, and problem solving ability
**NOTE: This model is very client involved –> Therapist role is in selecting and modifying activities
When is CO-OP used and what is the goal of CO-OP?
- Client has some AWARENESS of their deficits
- Client has EF deficits and primary focus of therapy (problem solving, planning, and organization)
- Client has the ability to engage in mutual goal setting (requires basic skills in memory, learning, attention, and motivation)
GOAL: Teach client a strategy they can use independently to solve future problems
EF Interventions
Strategy Training Goal
Strategy Training Techniques GOAL: increase self-awareness and control of cognitive processes -self-instruction training -problem solving training -goal management training -time pressure management
Specific for dealing slowed processing speeds = one of the most common complaints in CVA, TBI, MS, PD, and other neurological disorders
EF Interventions
Strategy Training Steps
Step 1: Teach client about executive functions that are impaired
Step 2: Teach the client strategies to improve functions (practice with strategies)
Step 3: Teach the individual methods to promote transfer of skills across context (practice with the strategies)
EF Interventions
Practice Settings
Extensive training in EF likely in OUTPATIENT settings
- outpatient cognitive rehabilitation setting
- home health care
- vocational training and rehabilitation
- outpatient day programs
OTHERS:
- Introduce strategies in inpatient, subacute settings (limited opportunity to practice with step 2, and a little opportunity to practice with step 3 due to time and facility constraints)
- -Self-instruction is easier to introduce, focus on BADL and simple IADLs
- GOAL-PLAN-CHECK-DO with simple IADL tasks
EF Interventions
Self-Instruction Training Goal
- Client verbalizes the action plan before and during the execution of the task
- GOAL: gradually fade verbalization
**over verbalization –> whispering –> internal talk
EF Interventions
Self-Instruction Training Levels of Support
Levels of Support
-Self-verbalization - talk through a script of the entire activity (high support)
- Self-guidance - talk through key reminders of plan (medium support)
- Self-questioning - pose a series of questions to double check performance (least support)
EF Interventions
Problem Solving Training (PST)
Teach clients to break down problems into smaller steps and use a step-wise approach to problem solving
5 steps:
1. Problem Orientation - recognize situations where a problem exists that needs to be solved
- Problem Definition - identify the main relevant information versus irrelevant information
- Generating Alternatives - generate as many possible solutions to problem as possible
- Decision Making - weight pros and cons of potential solutions
- Solution Verification - recognize bad solutions, self-correct errors, try other solutions
EF Interventions
Goal Management Training
- Use across multiple tasks
- provide cues and prompts to begin with –> gradually fade over time
- Journaling - client keeps track of perceived deficits in task performance before and after training (looks at self-awareness changes)
EF Interventions
PST vs GMT
Problem Solving Training (PST)
- Focus on the problem (I forget things when going grocery shopping)
- Focus is on developing multiple ways of addressing this problem
- More appropriate if the client has awareness about when problems occur but does not know how to prevent or solve the problems
- *More appropriate if the client doesn’t have awareness of has limited awareness about all the situations
- *where a problem occurs (works on increasing awareness)
Goal Management Training (GMT)
- Focus is on the occupation (getting dressed, going to the store)
- Focus is on predicting potential problems that could occur
EF Interventions
Time Pressure Management
-A structure problem solving strategy designed to deal with decreased processing speed
(address the problem of slow processing in multiple occupational areas)
3 Levels of decision making:
- strategic (long-term plans)
- Tactical (short-term, moment to moment adjustments in plans)
- Operational (if tactical fail, rapid decisions under time pressure, during task performance)
GOAL: To use task analysis and modification to reduce daily time demands so that client can complete tasks despite slow processing speed
EF Interventions
Compensatory Strategies
Environmental Modifications
- Reduce # of distractors in environment
More structure/less distraction –> less structure/more distraction
GOAL: achieve mastery in less demanding environment before moving to more demanding
- Cognitive scheduling/fatigue management to balance load of fatiguing decision making
EF Interventions
Compensatory Strategies
External Cueing Devices
- Checklists - self-instructional strategy
- Pagers
- Organizers/notebooks
