Continuing Education (CE)

This article has been approved for 1.5 Certified Brain Injury Specialists CE Credits and (Pending) 1.5 CCM CE Credits. To earn these credits, read the article and complete the associated form(s) located at the end of this article.


By: Angie McCalla, MS, CCC-SLP, CBIS
Speech & Language Pathologist, Clinical Team Leader, Rainbow Rehabilitation Centers

PART 1: Where is it controlled and how does it develop?

Executive Functioning Pie

Imagine you are on a diet and
are offered a piece of pie. You
might decline the offer. Why?
Because eating the pie conflicts
with your plans to lose weight.
Executive functions are the
mechanisms that kick in to help
us set goals, make plans and
change our behavior.

The executive functions are a set of processes that have to do with managing oneself and one’s resources in order to achieve a goal. It is an umbrella term for the neurologically-based skills involving mental control and self-regulation.

Executive functioning deficit is often used as a catch-all diagnosis for higher-order communicative-cognitive difficulties that are not clearly understood or diagnosable. Executive functioning (EF), when used to describe poor functioning, is often thrown about rather casually with minimal understanding of the immense impact the deficits can have on a person with said difficulties. Great strides have been made in identification and treatment with more and more practitioners realizing the devastating and often life-altering impact these subtle difficulties have on interpersonal skills, return-to-work potential, social communication and the ability to manage a home. In order to best treat executive dysfunction, we must understand brain anatomy as it relates to EF, definitions and models of EF, developmental acquisition of EF, remediation techniques, and future research directions.

This article and part two below will explore all of these concepts.

The Role of the Executive System

The role of the executive system is to handle novel situations outside of the domain of some of our more automatic psychological processes. Norman and Shallice (1992) outlined five types of situations in which routine activation of behavior would not be sufficient for optimal performance, and where executive functions must kick in.

  1. Situations that involve planning or decision making
  2. Situations that involve error correction or trouble shooting
  3. Situations where responses are not well-rehearsed or contain novel sequences of actions
  4. Dangerous or technically difficult situations
  5. Situations that require overcoming strong habitual response or resisting temptation

The executive functions are often evoked when it is necessary to override responses that might otherwise be automatically elicited by stimuli in the external environment. For example, when being presented with a potentially rewarding stimulus, such as a piece of pie, a person might have the automatic response to take a bite. However, where such a response conflicts with internal plans (having decided not to eat pie due to being on a diet), the executive functions might engage and inhibit the response.

Working Memory and Executive Functioning

There is also a connection between working memory and executive functioning. Working memory is a limited capacity system that temporarily maintains and elaborates information and supports human thought processes (Baddley, 2003). It is often viewed as the cornerstone or pivot point for higher order cognitive processes.

Based on Baddley’s model, working memory has three basic components: a central executive system and two subsidiary storage systems, the phonological sketch pad and the visuospatial sketch pad. The subsidiary systems are responsible for temporarily storing verbal and nonverbal information, where the central executive system processes information in working memory.

Serino et al.(2006) and Purdy state that in the initial stage of problem solving and goal-directed behavior, working memory is crucial. Working memory provides the storage and workspace for information, whereas executive functions perform operation on the information held in working memory so the information may be used efficiently. During working memory tasks that involve goal-directed behavior, the memory system, either verbal or nonverbal, must be strong in order to allow the executive system to determine the most suitable strategy from a set of alternatives, mentally checked and modified if necessary. Purdy, in the text Cognitive Communication Disorders, summarizes the interplay between working memory and executive functions in Figure 1.

Conceptualization of the relationships among attention, memory, executive functions and working memory

Conceptualization of the relationships among
attention, memory, executive functions and
working memory

What Areas of the Brain Control Executive Functioning?

Executive functions are located primarily in the prefrontal regions of the frontal lobe with multiple neuronal connections to other cortical, subcortical and brainstem regions. Neuroimaging and lesion studies from a variety of neurological diseases and injury models have confirmed the findings. However, it should be noted that prefrontal injury does not directly affect specific cognitive or linguistic processes; rather it affects their regulation and effective use, likely through alteration of the numerous neuronal connections between the prefrontal cortex and other brain regions.

If the distinction between a cognitive process and executive control over the process is not clearly drawn, assessment results may be incorrectly interpreted (e.g., normal scores on memory or language tests interpreted to mean that functional memory and language are intact) and inappropriate treatment prescribed (e.g., process-specific retraining exercises versus functional, contextualized, metacognitive intervention).

The dorsolateral prefrontal cortex (fig. 2) is involved in ‘online’ processing of information such as integrating different dimensions of cognition and behavior. The areas have been found to be linked to verbal and design fluency, ability to maintain and shift set, planning, response inhibition, working recall, organization skills, reasoning, problem solving and abstract thinking.

The anterior cingulate cortex is involved in emotional drives, experience and integration. Associated cognitive functions include inhibition of inappropriate responses, decision making and motivated behaviors. Lesions in this area can lead to low drive states such as apathy, abulia or akinetic mutism and may also result in low drive states for such basic needs as food or drink and possibility decrease interest in social or vocational activities and sex.

The orbitofrontal cortex plays a key role in impulse control, maintenance of set, monitoring ongoing behavior and socially appropriate behaviors. It also has a role in representing the value of reward based on sensory stimuli and evaluating subjective emotional experiences. Lesions can cause disinhibition, impulsivity, aggressive outbursts, sexual promiscuity, and antisocial behavior.

Definition and Models

Brain Diagram - Executive Functioning

Frontal lobe and prefrontal cortex

The executive system is a theorized cognitive system that controls and manages other cognitive processes. To date, there is very little agreement on one method or construct that
is the model of how the executive system functions. However, executive functioning involves complex cognitive processes. Elliot (2003) described a definition posited by Funahashi whereby executive functions involve “flexible coordination of sub-processes to achieve a specific goal.” Changes in framework have occurred over time and with gains in neuroimaging, further adaptations will occur. Typical models of executive functioning determine the skills to be either part of a hierarchy or as part of a metacognitive system.

Meta Cognitive MODELS

The word “metacognitive” generally means “thinking about one’s own thinking.” So, from that perspective, metacognitive systems stress “one’s ability to view, observe, and assess more basic cognitive procedures and includes self-awareness, selfmonitoring, and self-control of cognition while preforming an activity” (Kennedy & Coelho, 2005). It is a dynamic process that views lower order processes as automatic (outside of executive functions) and does not contribute to the higher order skill. Two models, the Supervisory Attentional System (SAS) and Miller and Cohen’s model are examples of metacognitive processes.

Executive functioning: Hierarchical models

Executive functioning: Hierarchical models

The SAS is centered on the idea that routine or well-established schemas automatically respond to routine situations while executive functions are used when we are faced with novel situations. Miller and Cohen (2001) presented the theory that the prefrontal cortex directs cognitive control and that the “control is implemented by increasing the gain of sensory or motor neurons that are engaged by task or goal directed elements of the external environment.” Their theory imparts that the action of the prefrontal cortex “is to guide the flow or neural activity along pathways that establish the proper mappings between inputs, internal states, and outputs needed to perform a given task.”

Hierarchical Models

Hierarchical models are based on the premise that executive functions receive input from lower level or more basic processes, such as attention and language, as well as higher level metacognitive processes. (Stuss, 1991). Figure 3 provides a summary of predominant hierarchical systems.

Functional Definition of the Executive System

With a variety of models to conceptualize EF, how can we sum up executive functioning in a cohesive understandable format? One way is to utilize a functional/operational definition of the executive system shown in Figure 4.

Executive Functioning Figure 4

Functional definition of the executive system

Development Across the Life Span

Genetics and environment have an influence on how one develops higher-order cognitive skills. Gender also plays a role. Despite these influences, some generalizations can be made across the life span about executive functioning development.

Executive functions develop across the life span with the first signs noted in infancy. Research has shown inhibitory control and working memory skills emerging in children as young as 7-12 months. This is seen through means-end development. The child is able to hold one piece of information in mind in order to act on another. The skill is very fragile and highly susceptible to distraction.

By the age of one, children begin to display gains in selective attention with external distraction not as predominate.

At the age of two, children become more capable of problem solving with the acquisition of language. They begin to use language to regulate behavior. At two, children are also able to follow verbal rules, requests and directives. They are beginning to keep verbal rules in mind and use them to guide their behavior. Gains in rule and language use continue to grow and impact learning.

By three years of age, the child is no longer impulsively responding to stimuli in a rigid stereotyped means but rather acting deliberately and flexibly in light of a conscious plan.

Between the ages of three and five, children demonstrate significant gain in performance on tasks of inhibition and working memory. They are beginning to reflect on their own actions. Cognitive flexibility, goal-directed behavior and planning gains are noted. They are developing complex sets of rules to guide/regulate their behavior. They begin to ‘think’ about the intention or the act of doing rather than simply responding to the environment.

As children mature and change, they continue to gain in inhibitory control, and attentional capabilities are noted. During the primary school years and into early adolescence, the main changes are made in the ability to consider variables and act accordingly. Preschoolers can verbalize their knowledge of what is the right thing to do but often are not able to actually follow through on it. The need for immediate gratification overrides planning and reasoning capabilities. Further, their ability to successfully implement strategies to limit impulsive responses are not yet developed, though emerging.

Executive Function development with age

Executive Function development with age

External supports and modeling provide reinforcement and help internalize strategies. Gains in planning, goal setting/ directed behaviors problem solving and cognitive flexibility are continuing and providing the basis for social skills and academic success during pre-adolescence and adolescence.

The role of executive function development is most clearly demonstrated and often most acknowledged during the teenage/ adolescent years. This is in part due to high-risk behaviors that are observed during adolescence, such as alcohol/drug use and unprotected sex.

9 Key Executive Functions

  1. Awareness —Age-appropriate insight of strengths and weaknesses.
  2. Planning —Spontaneous use of planning behaviors in novel tasks; anticipate future events; grasp main idea; prioritize, reduce/cluster information, re-arrange material or information.
  3. Goal setting —Set intermediate and long-term goals appropriate to abilities.
  4. Self-initiation —Independently initiate new activities; spontaneous in conversation; begins activity without procrastination, seek and search for information, generate ideas, persist, complete all parts of an activity.
  5. Self-monitoring —Independently assess behaviors/ responses and make changes as needed.
  6. Self-inhibiting —Behavior is appropriate to changing situations; control impulses, think before acting, pace actions; follow or select according to rules or criteria; manage extraneous distractions, irrelevant information or interference; delay responses.
  7. Ability to change set —Demonstrate appropriate variations in behaviors; independently consider a variety of solutions in problem solving; revise plans, move freely from one step/activity/situation to another; transition between tasks easily.
  8. Strategic behavior —Create useful strategies for functional use; able to describe these.
  9. Working memory —Hold information in mind for the purpose of completing a task.

By the age of 15, working memory, inhibitory control and the ability to sustain and appropriately shift attention are close to adult levels and remain relatively stable with some small increases noted into adulthood. Though, the teen is functioning at or near adult levels, their self-monitoring and self-reflective abilities are not fully mature. Further, when placed in highly complex situations or a situation in which one is required to integrate numerous pieces of information to make an informed decision, the teen will show shortcomings. They tend to base decisions on the advantage of a given situation versus the disadvantages.

Decisions and actions are based on the specific moment and do not consider the long-term consequences, rather making decisions based on their view of themselves at the moment and how they will be perceived by outsiders.

Dr. Zelazo (2010) explains the shortcoming as a “competition between the top-down influence of executive function and the bottom-up influence of desires, drives, impulses and habits.”

As the executive system matures, adults are able to use stored knowledge about themselves and draw on their past experience in making decisions.

In adulthood, gains and decline in executive skills are noted. Between the ages of 20-29, executive functioning skills are at their peak. Decisions regarding marriage, career, family and long-term goals are stable, reflective and highly obtainable. Consideration to outside influences are weighed with internal drives to develop the best outcomes.

As the adult ages, executive functions once again change but this time showing a decline. Declines in higher order cognitive skills have been clearly noted in working memory, self-monitoring, and spatial skills. What has been thought of as normal changes in aging may be the result of an aging in the prefrontal cortex and demyelination—a deterioration of the myelin sheath surrounding neurons which results in a slowing of impulses that travel along the nerve.

The adage of “use it or lose it” may very well be true in the realm of executive skills. Continued cognitive involvement/ stimulation may promote neuronal myelination or, at minimum, slow the course of demyelination contributing to greater quality of life, independence and overall functional skill.

PART 2: Remediation Techniques for Deficits and Dysfunction

Executive functions are located primarily in the prefrontal regions of the frontal lobe of the brain with multiple neuronal connections to other cortical, subcortical and brainstem regions. Injury to the prefrontal area does not directly affect specific cognitive or linguistic processes; rather it affects their regulation and use, likely through alteration of the numerous neuronal connections between the prefrontal cortex and other brain regions.

When this area of the brain is damaged due to a traumatic brain injury (TBI), remediation of executive functioning (EF) skills aims to increase the person’s awareness of deficits, identify relevant Brain Diagram - Executive Functioningstrategies and set goals to promote goal-directed cognitive functioning.

Intervention strategies are typically delivered in one of three manners: metacognitive strategy training, problem-solving strategies and group/day treatment. Each strategy relies on fundamental building blocks and incorporates the use of self-directed strategy.

Remediation—base skills set

The building blocks or base skills set of executive functioning remediation are based on three assumptions:

  1. At the core of executive dysfunction is a disruption of the problem-solving mechanism.
  2. Problem solving is supported or thwarted by emotion.
  3. Executive function, problem solving and emotional regulation are mediated by attention. (Gordon, Cantor, Ashman & Brown, 2006).

Each core behavior of problem solving, emotional regulation and attention must be addressed and regulated in order for dysfunction to be eliminated or modified. When done in succession or tandem, the clinician and client can effectively move from base skill training to directed intervention of executive functions.

Problem Solving

Problem solving and executive functioning has been widely researched; however, one of the most widely referenced studies are those of Alexander Luria, a noted Russian neuropsychologist and developmental psychologist. Luria noted that persons with frontal lobe lesions had significant difficulty analyzing problems in a systematic manner. He also noted a lack of ability to identify important connections/relationships between corresponding information. (1966)

The ability to form a concise conclusion was absent or significantly impaired. The person had no specific plan, did not appear to engage in review of the nature and constraints of the problem and thereby evidenced impulsive actions.

Luria advocated for remediation to focus on the specific aspects of problem solving—anticipation, planning, execution, and self-monitoring.

Emotional Regulation

Emotional regulation (ER), the ability to maintain a well regulated emotional state to cope with everyday stress, plays a significant role in all aspects of cognitive-linguistic function–executive functioning is not excluded. Cognitive-behavioral theory as applied to problem solving, predicts that emotions may hinder or facilitate problem solving (Gordon,, 2006) If, as Luria states, problem solving is the basis for executive function skills, ER must be a focus of intervention.

Rath, Simon, Langenbahn, Sherr, and Diller (2003) support Luria’s hypothesis stating that emotional regulation is the foundation of the process that make up problem solving. Thoughts and beliefs about problems and the impact of those beliefs on a person’s ability to recognize the problem, and act on them, is the focus of ER training.

The primary purpose of the training is to help reduced emotional “noise” and negative self-talk (Gordon, et al, 2006). They detail a three-part strategy for emotional regulation in dealingwith problem situations:

  1. Observation of behaviors, emotions, thoughts, and physiological experiences that occur in response to problem situations and the ways in which they interfere with problem solving.
  2. Analysis of precursors, with a focus on contexts, triggers and warning signs of maladaptive emotional responses to problem situations.
  3. Reframing and planning, in which participants use strategies for self-regulation of emotions. Strategies include: recognition of illogical, maladaptive, and inaccurate thoughts; use of positive self-talk and reframing; and use of behavioral techniques such as relaxation breathing.


Attention training is noted to be the basis for remediation of recall, information processing and executive functions. During attention training, an individual listens for a specific target in a field of many, e.g., listening to the sound of a train, birds chirping and a bell ringing all at the same time. When they hear the target, they press a button to indicate/acknowledge that the stimulus just passed.

Vigilance is key to intentional learning. Shallice (1981)

hypothesized that regulation and verification of behavior are controlled by an attentional supervisory executive system. Stuss, Shallice, Alexander, and Picton (1995) believe attention and executive function are intimately related.

A variety of studies, most notably those conducted by Sohlberg and Mateer in development of the Attention Processing Training protocol, indicate that attention training alone can result in improved anterograde (short-term) memory. Attention training is completed prior to implementation of highly targeted metacognitive and/or problem solving paradigms. The individual must first display high levels of vigilance before self-reflective and goal-directed interventions can be implemented. These interventions rely on the individual monitoring behaviors, establishing a set and realistic view of what they can and cannot do.

This three-part paradigm proposes to inhibit both impulsive and “do-nothing” responses. By reducing emotional dysfunction, the individual is able to focus on and develop strategies to increase awareness. Emotional noise no longer interferes with skill building and self-reflection. All resources are in synchrony.

Transition to Formal Executive Training

Gordon, et al. outlined strategies to maximize learning and to assist with transition to formal executive function training.

  1. Contextualized learning—When presenting situations or information, learning takes place best when encountering day-to-day problems in real-life situations.
  2. Strategies must be repeatedly presented in a structured manner, embedded in all treatment context and must draw on real-life problems.
  3. Top-down approaches to learning, characterized by a high level of direction, are more likely to be effective in treating executive dysfunction. This approach involves learning and use of general strategies that can be applied to a variety of contexts. Conversely, bottom-up approaches emphasize the repetition of exercises and drills that focus on improvement of a specific task.
  4. Learning is facilitated by multiple opportunities to apply what has been learned in a variety of situations.

Formal Executive Functioning Programs

Formal training follows guidelines that are based on the practice recommendations and guidelines of the Cognitive Rehabilitation Task Force of the American Congress of Rehabilitation Medicine (ACRM) Brain Injury Interdisciplinary Special Interest Group (BI-ISIG). The training guidelines were developed from three systematic reviews of the cognitive rehabilitation literature with the most recent reviewing literature from 2003-2008 (Cicerone, 2000, 2005 and 2011). From the review, a practice standard, practice guideline and practice option for remediation of executive dysfunction were derived. ?

  1. Practice standard—metacognitive strategy training (selfmonitoring and self-regulation) for deficits in EF after TBI, including impairments of emotional regulation, and as a component of interventions for deficits in attention, neglect and memory.
  2. Practice guideline—training in formal problem-solving strategies and their application to everyday situations and functional activities in post-acute rehab.
  3. ?Practice option—group-based interventions.

Practice standard: Metacognitive Strategy TrainingExecutive Functioning Chart

Metacognitive strategy training focuses on improving one’s metacognition or “thinking about thinking.” Metacognitive knowledge includes both a person’s online awareness of their thinking and their beliefs about their cognitive abilities.

Metacognitive control is the self monitoring of thinking and the ability to adapt to changes in the environment or task-demands. (Kennedy, et al.,2008) Metacognitive strategies follow a topdown approach. Top-down approaches involve learning and use of general strategies that can be applied to a variety of contexts. As opposed to bottom-up approaches that emphasize the repetition of exercises and drills that focus on improvement of a specific task.

Metacognitive training teaches the individual to evaluate their own performance and to gain awareness. Increased awareness is fostered through teaching self-monitoring, self-evaluation, prediction, and anticipation of difficulties. Initial training utilizes external aids to foster problem solving and promote integration of rule-based behavior. As trials progress and the strategy is integrated, the external strategy is faded and the strategy becomes internalized.

The BI-ISIG highlights Self-Talk Procedures as a metacognitive strategy, specifically the work of Cicerone and Giacino (1992) and Sohlberg and Mateer (2001). Both procedures incorporate the use of faded verbalizations: overt verbalization, transition to faded verbal self-instructions (whispering), and then to covert verbal mediation (inner talk). Each framework instructs the person to talk through the steps of the task while doing the actions.

As gains in ability are noted, the verbalizations become more internalized. If breakdown occurs at any stage of the task, modeling and cues are provided to promote success and to serve as a launching point for the next attempt.

Sohlberg and Mateer proposed a 10-step treatment plan that emphasizes pre-planning and identification of specific executive functioning deficits to ensure the self-talk action plan was highly specified. Cicerone and Giacino’s treatment plan incorporates use of planning worksheets and outlines to assist in structuring the self-talk procedure. Selftalk/verbal self-regulation procedures have been successful in advancing the cognitive aspects of instrumental activity of daily living (IADL) performance and promoting self-regulation (Goverover, 2007). The use of self-talk lends itself well to IADL due to relatively concrete nature of the task and the transparency of outcomes.

Metacognitive training can be used to facilitate gains in awareness. Awareness training can be highly complex and largely relies on the incorporation of feedback and educational materials. The ACRM manual outlines a four-step system to facilitate awareness: identifying the problem, clarifying the problem, planning a solution and finally implementing, monitoring and adapting.

1. Identifying the problem

The first step of awareness training is identification of a specific area of behavioral, emotional and/or cognitive dyscontrol. Once targeted, intervention focuses on understanding the underlying impairment and the consequences of such behaviors.

Following identification, education is provided. Education is the key component of a successful awareness training plan. Education is provided in a variety of ways, both visual and verbal.

Continuous study of educational material assists with incorporating ideas and a beginning recognition of challenges. The ACRM notes, “education materials provide concrete information in a simplified form to minimize demands on memory or organizational abilities.” The manual also stresses keeping track of symptom indicators as a means of gaining injury related understanding.

Persons are often better at recall/ understanding the symptom indicators (not able to find specific papers or getting lost on the way to a new place may indicate difficulties with spatial organization and planning) versus naming a problem in a global sense.

If awareness is not gained or improvement is minimal, the provision of evidence is given. Providing evidence of situations in which one does not “behave” as expected is extremely sensitive. All work must be highly collaborative and deemed safe and respectful by both parties.

Supportive, non-confrontational dialogue must be the hallmark of training.  Use of reflective questioning, observational data/information, and feedback can foster improved awareness. Signs of decreased awareness include: repeated failures, discrepancy between performance and others observations, poorly controlled emotions, and repeated conflicts with others. “The goal is not to highlight a person’s failures but rather to raise their awareness” (Haskins, 2012).

2. Clarifying the problem

Clarification of the problem allows for targeted intervention plans. Information is gathered on the frequency, antecedents, outcomes, strategies used to assist.

Ways to gather information include daily notebooks, structured recording sheets, or simply journals. Information should be garnered from both the individual and if possible those interacting with them on a daily basis.

Clarification of the problem entails understanding the underlying cause of the difficulty/challenge. Understanding the cognitive process that influences actions and behaviors is required to effectively implement a successful solution.

3. Planning a solution

The third step in the development of awareness is development of a solution. The solution must be directly derived from the nature of the problem (ACRM manual 2012).

A variety of studies (Sohlberg and Mateer 2001; Rath et al., 2003; Rath et al., 2006; Levine et al., 2000) stress that labeling a problem will promote successful rehabilitation. The name given involves components of the problem and assists with recognition of the problem and in training external supports of the problem and what intervention strategies to employ. The name helps to focus rehabilitation and allows the individual to readily retrieve and address deficits in naturalistic situations. The problem becomes less obtuse and more concrete.

Studies found that gains were noted in solution generation when the task was specifically named despite the nature of the task—pen and paper (Rath et al., 2006), time pressure management (Fasotti, et al., 2000), goal management training (Levine et al., 2000), and teaching internal memory strategies to problem solving therapy (Von Cramon, 1991).

Once the problem is labeled, intervention shifts to generating all possible solutions and then determining the advantages and disadvantages of each. Self-evaluation and reflection are stressed as solutions are evaluated for potential implementation.

4. Implementing, monitoring, adapting

The final step in awareness training is implementing, monitoring and adapting the solution. The solution is put into practice. Initial trials include role-play and structured feedback sessions following task completion. Self-monitoring and regulation are key at this point of the process.

Practice Guideline: Problem-Solving Strategies

Problem-solving strategies follow a relatively simple and consistent practice standard. Gains in executive function are facilitated through use of the simple questioning strategies. All problem-solving strategies follow a highly structured format (Haskins, 2012): ??

  • What is the problem? ??
  • Set goals ??
  • Plan a solution ??
  • Execute the solution ??
  • Monitor feedback and make changes, if necessary

As with metacognitive training, a topdown approach is used to improve performance. The BI-ISIG recommends patients to be trained to apply the same general strategy to all new problems they encounter.

In the initial phase of training, highly structured written worksheets are implemented. Each step of the problemsolving sequence is recorded. The plan is then implemented and the outcome noted, both successes and failures. The problem-solving techniques are practiced across a variety of settings, tasks and situations. With consistent use, the strategy/sequence becomes habitual and the written sequence can be faded. It is the overall goal of the program to make the sequence habitual across a variety of situations with limited use of external cues.

When successful, problem-solving strategy training shifts to metacognitive training in the form of self-talk. If the nature of the injury is severe and internalization cannot be achieved, external compensatory strategies in the form of structured problem solving sheets or cues should be utilized.

Implementation of a goal-setting procedure follows a standard outline: acquisition, application and adaptation (Gordon, et al., Cicerone, 2008, Ylvisaker and Feeney, 1998, Turkstra and Flora 2002, Rath et al., 2003, Haskins, 2012). ??

  • Acquisition – The outline and steps of the problem-solving procedure are learned. Education is provided on the justification of each step. Successful completion is noted when the individual can independently recite the steps and rationale of the procedure. If underlying impairments limit the person’s ability to independently recall problem-solving steps, the strategy will shift to an external compensatory strategy versus eventual internalization (self-talk/ self-questioning) ??
  • Application – The problem-solving procedure is put into practice within the clinical setting. A variety of tasks are presented and consistent practice is given. Problem-solving forms are utilized to promote effective and efficient tasks completion. Self-reflection and evaluation are encouraged following all tasks. Completed problem solving forms should be kept to use for reference. ??
  • Adaptation – The problem-solving procedure is applied to tasks and situations outside the clinic. Use of the formal problem-solving forms is permissible but at this point the person will most likely have internalized the strategy.

Practice Option: Group-based Interventions

In addition to pure metacognitive strategy and problem-solving training, the literature supports use of strategies that entail group work, environmental alteration, skill-based and behavioral learning paradigms. The focus of intervention results in similar outcomes – advancement in awareness and IADL function; however, the strength of research is limited thus they are not included as practice standards or guidelines to date. The additional protocols listed above support implementation with more severely impaired persons as the focus on internalization of strategies is far less.

Cicerone, et al. (2008) evaluated the effectiveness of comprehensiveholistic neuropsychologic rehabilitation compared to standard multi-disciplinary rehabilitation. Holistic neuropsychologic rehabilitation includes individual and group therapies that emphasize metacognitive and emotional regulation for cognitive deficits, emotional difficulties, interpersonal behaviors, and functional skills. Standard multi-disciplinary rehabilitation included individual discipline specific therapies along with one hour of individual cognitive rehabilitation.

Results indicated improvement in both groups but the holistic group produced greater improvements in community functioning and productivity, self-efficacy and life satisfaction. The findings indicate that comprehensive therapy can improve community integration and functional independence even for patients many years post injury.

Environmental approaches include manipulating the environment by providing external supports for desired behaviors. It is most useful for patients with severe cognitive impairments whose function is facilitated in tightly controlled settings and who require close supervision to monitor behavioral dyscontrol and difficulties planning or organizing sequences of behavior necessary to perform simple tasks of daily living. Reminder systems for medication management, appointment reminders and scheduling, and daily sequences are viewed as environmental applications.

Skill-based learning teaches one to how to manage a specific problem by providing repetition learning until the skills to be learned becomes automatic. The approach is successful with all levels of impairment but in particular those with attentional and memory problems. The person is taught cues that help to identify a difficult situation and are taught adaptive strategies to replace maladaptive ones. Learning is often task specific with limited generalization.

Behavioral programming follows a traditional approach. The therapy involves use of behavioral reinforcement, focusing on both antecedents and consequences of behaviors, to increase desirable behaviors and reduce undesirable behaviors.

Group day treatment models have been show effective in relation to improving rehabilitation outcomes for persons with executive functioning deficits (Malec and Basford 1996, Gordon and Hibbard 1992, Rath et al, 2003). Rath et al. taught emotional self-regulation as a basis for effective problem-orientation and a necessary precursor to support training in the clear thinking underlying problem-solving skills.

Role playing was used to promote internalization of self-questioning, use of self-regulation and systematic analysis of real-life problem situations. They found that only the problem-solving treatment resulted in significant benefit on measures of executive functioning, selfappraisal of emotional self-regulation and objective observer-ratings of interpersonal problem solving behaviors in naturalistic situations.

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