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The Source® for Executive Function Disorders
Ages: 16-Adult   Grades: 11-Adult

Target specific high-level cognitive processes in your clients with executive function disorder with activities that can be individualized to their needs and interests.

Outcomes

  • Determine which areas of executive function interventions are appropriate
  • Use the Patient-Initiated Continuum to target high-level cognitive/language skills
  • Clients improve their skills in self-regulation, time management, attention, organization, and memory
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Executive functions perform a collective service that comes into play with all facets of cognitive processing.  Patients with executive function disorders have difficulty with:

  • planning and organization
  • identifying what needs to be done
  • carrying out the steps in an orderly way
  • identifying the beginning tasks
  • maintaining attention
  • evaluating how they're doing on a task
  • taking feedback or suggestions

This manual provides a structured framework for therapists to guide the evaluation process and treatment of patients with executive function disorders.  The manual gives:

  • information on the use of standardized and informal assessment tools to reflect the patient's real-life performance
  • instruction in the use of the Patient-Initiated Continuum (PIC) to involve the patient as a stakeholder in therapy and to quantify patient improvement
  • thorough explanations of the processes of time management, attention (five forms), goal-directed behavior, and memory
  • activities to systematically target self-assessment, time management, attention (five forms), goal-directed behavior, and memory
  • examples of goals and written reports
  • documentation requirements

Copy the activity pages or print them from the FREE CD.  Extra helps include:

  • patient history form
  • patient self-assessment checklists
  • patient performance checklist
  • time management templates
  • 65 pages of reproducible activities
  • answer key

Copyright © 2003

Components
211-page book plus a CD of reproducible pages, answer key, checklists, forms, therapy activities
  • Executive functions are a group of cognitive skills localized in the frontal lobe structures.  Deficits in executive functioning involve both discrete skills and the processes that control the use of these skills (Cicerone et al., 2000).
  • Executive function deficits, including weakness in the areas of self-awareness, goal setting, and strategic thinking, are often among the most debilitating problems following brain injury (ASHA, 2003).
  • In assessing and treating executive function deficits, it is important to collaborate with the patient in selecting goals, testing treatment hypotheses, identifying strategic compensations, and monitoring results (ASHA, 2003; Cicerone et al., 2000).
  • Effective intervention is measured by the reduction of supports needed by the individual with a disability (ASHA, 2003).

The Source for Executive Function Disorders incorporates these principles and is also based on expert professional practice.

References

American Speech-Language-Hearing Association (ASHA). (2003). Rehabilitation of children and adults with cognitive-communication disorders after brain injury [Technical Report]. Retrieved March 10, 2009, from www.asha.org/policy

Cicerone, K., Dahlberg C., Kalmar K., Langenbahn, D., Malec, J., Bergquist, T., . . . Morse, P. (2000). Evidence-based cognitive rehabilitation: Recommendations for clinical practice. Archives of Physical Medicine & Rehabilitation, 81(12), 1596-1615.

Author(s)

Susanne Phillips Keeley

Biography

Susanne Phillips Keeley, M.S., CCC-SLP, earned degrees in Communication Disorders & Speech Science and Psychology from the University of Colorado.  She received her M.S. in Speech-Language Pathology from Northwestern University and continues to work and live in the Chicago area.

She has specialized in the evaluation and treatment of adult neurological disorders in many settings, including inpatient acute care, outpatient, acute rehabilitation, home care, and private practice.

The Source for Executive Function Disorders is Susanne's first publication with LinguiSystems.

Introduction

Comments to Therapists

The increasing prevalence of brain damage as a result of head trauma, stroke, or a tumor has resulted in a need for therapists skilled in the evaluation and treatment of this population.  Materials developed for language-impaired individuals have not always been appropriate, and consequently, there has been an increase in the amount of commercially-available material targeting the brain-injured adult population.  Most of these treatment manuals contain activities appropriate for levels of severity that range from mild to severe.  Frequently, high-level assessments and treatment activities are mixed with lower-level tasks within the text.  Often, they do not provide the comprehensive consideration the executive function disordered population requires.  Using tasks designed for low-level patients and increasing the linguistic/attention/memory parameters of the task alone is not sufficient.  Activities related to the patient's life and what the patient finds interesting are most likely to be effective.  However, it is difficult to find specific task-training activities at the high level that could engage a patient for more than a few minutes, and certainly not an entire treatment course.

Because this book is devoted to rehabilitation practice, it assumes basic knowledge of neuroanatomy, neurophysiology, neurological disease/impairment, and the mechanisms of brain injury.  It contains activities for both the therapist and the patient.  It is based on the premise that the patient is the best interpreter of his or her particular impairment.  It is the therapist's responsibility to ask the right questions in order to obtain this information, substantiate the complaint with evaluation tools, design treatment activities that address the deficit areas, and monitor progress.  This manual provides a structured framework for therapists to guide the processes of evaluation and treatment of patients with executive function disorders.

Results of studies have illustrated the improvement of cognitive functioning via theoretically-based rehabilitation exercises that methodically target specific processes.  The Source for Executive Function Disorders contains contrived, highly clinical activities systematically targeting specific processes.  It goes the extra step, however, to assist the therapist in applying therapeutic remediation to activities in the patient's daily life.  Of utmost importance is the therapist's ability to think and analyze.  This manual will instruct the therapist in determining which areas and activities are appropriate for each individual client, the structured and systematic presentation of treatment stimuli, and important components of documentation.

Because of the high level of the activities necessary to treat patients with executive function disorders, the therapist must possess a certain level of skill with his or her own executive functions.  For example, the therapist will be required to break down tasks into their component parts, train in methods of prioritization, and participate in difficult alternating and divided attention tasks.  Just as not every speech-language pathologist has the "ear" to be a good voice therapist, without extra work and effort, not every therapist will fall into executive function treatment easily.  Work through the activities in this manual yourself.  Try them with your friends and family, and begin to develop a feeling for the wide range of normal.

What Are Executive Functions?

As one advances hierarchically through the animal chain, a larger portion of the brain's cortex is devoted to the frontal structures.  This region of the brain is the most modern in evolutionary development, and it is the last to develop and mature in an individual.

The frontal lobes of the brain are marked by their neuroanatomic diversity.  The frontal lobes have numerous connections to other sections of the brain, and the functions they carry out are the product of information collected from many locations in the central nervous system.

The frontal lobes are not only accountable for primary cognitive functions but also for coordinating and actualizing the activities involved in cognitive processing.  The frontal lobes coordinate input from other sections of the brain, and they function to organize and regulate behavior necessary to reach accomplishment of certain tasks.  The frontal lobes are fundamental to the executive functions of anticipation, goal selection, planning, self-monitoring, use of feedback, and completion of purposeful activities.

The anatomical positioning of the frontal lobes leaves them sensitive to injury.  They rest against rough, bony protuberances of the inner, anterior skull and, as the result of head injury, are easily scratched or bruised.  Damage to the frontal lobes results in a combination of behavioral and emotional deficits and cognitive problems—specifically, decreased executive functions.  Executive functions do not portray a single, distinct process. Instead, executive functions perform as a collective service that comes into play with all facets of cognitive processing.

Executive functions are a collage of cognitive activities that encompass the ability to design actions toward a goal, to handle information flexibly, to realize the ramifications of behavior, and to make reasonable inferences based upon limited information.  Additionally, executive functions can be thought of as encompassing such activities as anticipation, goal selection, planning, initiation of activity, self-regulation or self-monitoring, and use of feedback.  The executive functions are detailed functions of logic, strategy, planning, problem solving, and reasoning.

Impairment of any or all of these executive functions may be present in spite of strong intellectual skills and unaffected language capacity.  When executive functions are impaired, all other cognitive systems have the potential to be affected, even though those same systems may remain undiminished in isolation.  Individuals with executive function impairments have difficulty with planning and organization.  They are unable to identify what needs to be done and/or are unsure of how to accomplish the steps to completion in an orderly way.  Individuals often appear inattentive and disorganized.  Frequently, they miss deadlines, are late for appointments, or overschedule themselves.  People with executive function impairments demonstrate difficulties with initiation as well as experience pitfalls in beginning tasks.  This may be evident by the person sitting idle when directly asked to do something, or in a more subtle form, by someone appearing less spontaneous or less energetic than might otherwise be expected.  Once the person begins a task, he or she may have problems maintaining attention to the task or in persisting to the end.  With executive function impairments, self-monitoring and self-regulation become arduous.  People with executive function disorders are inconsistent in their performance and have problems integrating feedback or suggestions.

Executive function disorders are characterized by the following:

  • difficulty with planning and organization
  • trouble identifying what needs to be done
  • problems determining the sequence of accomplishment
  • difficulty carrying out the steps in an orderly way
  • difficulty beginning tasks
  • problems maintaining attention
  • trouble evaluating how they are doing on a task
  • difficulty taking feedback or suggestions

Case Studies

  1. KB is a 35-year-old male who was injured when a ceiling fell on him.  He reportedly lost consciousness for a short period of time (5-10 minutes) and was taken to the emergency room.  He was treated and released.  Since that time, he reported being unable to work and experienced a variety of physical, cognitive, and emotional difficulties.  He reported difficulties with attention, organization of thought in both speaking and writing information, and poor time management.  KB earned a B.A. degree from a large university and, at the time of his accident, owned a special events planning business.  At the time of his injury, he had several events mid-project, which he completed, but per his and his clients' reports, at a substandard level.  Since completing these projects, he has been unable to accept new projects or solicit new clients stating, "I know I should, but I just can't seem to do it."
  2. LE is a 33-year-old female who was in a car accident.  She reported loss of consciousness for a "few minutes."  She noticed a decline in her memory since the accident, but she attributed this to medication she was taking for the back pain she developed from the accident.  The changes in memory persisted even after she discontinued use of the medication.  At the time of the accident, LE was enrolled in the last quarter of an M.B.A. program in finance and international business, earning A grades.  She completed her last quarter, earning C grades and feeling she "learned very little."  LE has been unable to look for a job since completing her degree.  She says that she "reads the paper and doesn't see any jobs" appropriate for her.  She has not developed a resum√© or enlisted the help of her college placement department.  She has moved back home with her parents.
  3. JW is a 48-year-old male diagnosed with a left frontal lobe brain tumor.  The tumor was resected and found to be benign.  No chemotherapy or radiation was indicated.  JW described struggling to keep up the responsibilities of his job as a director at an advertising agency.  He reported daydreaming during meetings, missing important meetings even though he had thought about them earlier in the day, and being unable to do more than one thing at a time.
  4. PS is a 42-year-old male who was in his usual state of good health when he fell off his bike and lost consciousness.  A CT scan identified a skull fracture on the left with blood present in the right frontal area.  Since the accident, he noted decreased concentration, short-term memory difficulties, and organizational problems.  He is a self-employed manufacturer's representative and a single father of four children ages 7-18 who live with him.  PS's major complaints revolved around home activities as opposed to work.  He reported frequently failing to finish the laundry and finding wet clothes days later in the machine.  He was often late for scheduled pick-ups of his children and reported feeling very irritable when helping with homework, a task he previously enjoyed doing.