Mark Ylvisaker

Intervention for executive functions after traumatic brain injury: A systematic review, meta-analysis and clinical recommendations

A systematic review of studies that focused on the executive functions of problem solving, planning, organising and multitasking by adults with traumatic brain injury (TBI) was performed through 2004. Qualitative and quantitative methods were used to evaluate the 15 studies that met inclusion criteria. Demographic variables, design and intervention features, and impairment and activity/participation outcomes (ICF) (World Health Organization, 2001) were documented. Five randomised control treatment (RCT) studies used step-by-step, metacognitive strategy instruction (MSI) and outcomes were evaluated in a meta-analysis. Effect sizes (ESs) from immediate impairment outcomes after MSI and “control” intervention were similar to each other, and both were significantly larger than chance. ESs from immediate activity/participation outcomes after MSI were significantly larger than the ESs from control intervention, and both were significantly larger than chance. These results, along with positive outcomes from the other group, single-subject design and single case studies, provided sufficient evidence to make the clinical recommendation that MSI should be used with young to middle-aged adults with TBI, when improvement in everyday, functional problems is the goal (Level A) (American Academy of Neurology, 2004). Although maintenance effects were generally positive, there was insufficient data quantitatively to evaluate this. Furthermore, there was insufficient evidence to make clinical recommendations for children or older adults. Intervention that trained verbal reasoning and multi-tasking was promising, although the evidence is insufficient to make clinical recommendations at this time. Additional research needs were highlighted.

Direct clinician-delivered versus indirect family-supported rehabilitation of children with traumatic brain injury: A randomized controlled trial

Primary objectives: To explore the relative effectiveness of clinician-delivered vs family-supported interventions for children with chronic impairment after TBI. Research design: Randomized controlled clinical trial. Methods and procedures: Children aged 5–12 years in the chronic phase of their recovery were randomly assigned to the clinician-delivered or to the family-supported intervention group; both samples received intensive services for 1 year; physical outcome was measured by the SARAH scales, cognitive outcome by the WISC-III. Main outcomes and results: Parents in the family-supported intervention sample efficiently acquired the skills needed to deliver physical and cognitive interventions within the context of everyday routines of the childs life at home; family education level was not a factor. Although both groups demonstrated improvements, only the children in the family-supported intervention group demonstrated statistically significant — and clinically important — improvements on both outcome measures. Conclusions: This RCT provides compelling evidence for organizing cognitive and physical interventions and supports for children with TBI around the everyday routines of their lives, with intensive supports for their families.

Behavioural interventions for children and adults with behaviour disorders after TBI: A systematic review of the evidence

Objective: To systematically review the evidence for the effectiveness of behavioural interventions for children and adults with behaviour disorders after TBI. Design: Using a variety of search procedures, 65 studies were identified. This literature was reviewed using a set of questions about participants, interventions, outcomes and research methods. Participants: The 65 studies included 172 experimental participants, including children and adults. Interventions: A number of specific intervention procedures were used, falling into three general categories: traditional contingency management, positive behaviour interventions and supports and combined. Results: All of the studies reported improvements in behavioural functioning. Conclusions: Behavioural intervention, not otherwise specified, can be considered a treatment guideline for children and adults with behaviour disorders after TBI. Both traditional contingency management procedures and positive behaviour support procedures can be said to be evidence-based treatment options. However, a variety of methodological concerns block stronger conclusions.

Rehabilitation and ongoing support after pediatric TBI: twenty years of progress.

This article summarizes major developments of the past 20 years in both acute and chronic management of children with traumatic brain injury. The article begins with brief summaries of developments in acute and rehabilitative medical management and physical rehabilitation. Because long-term cognitive, behavioral, academic, and family issues tend to be dominant after pediatric TBI, more attention is given to these topics. The article ends with a list of general themes that have been identified as critical in providing effective long-term services and supports to children with TBI and their families.

Educating students with TBI: themes and recommendations.

Ten educational consultants and researchers, each with extensive experience working with children with traumatic brain injury (TBI) in school settings, identified seven themes related to serving this population in public schools. These themes are discussed under the headings (1) incidence of TBI and prevalence of persistent educational disability, (2) diversity and central tendencies within the population, (3) assessment, (4) intervention and support in school settings, (5) training and support for educators, (6) intervention and support for families, and (7) systems change and flexibility. For each theme, a set of recommendations is provided, forming an educational research and policy agenda for pediatric TBI.

Positive supports for people who experience behavioral and cognitive disability after brain injury: A review

Background:Behavioral and cognitive problems are among the most common and troubling consequences of traumatic brain injury. Furthermore, behavioral and cognitive challenges typically interact in complex ways, necessitating an integrated approach to intervention and support. Objectives:This article reviews literature on behavioral outcome in children and adults with traumatic brain injury, traditional approaches to behavioral intervention and cognitive rehabilitation, and the history, principles, and assessment and treatment procedures associated with context-sensitive, support-oriented approaches to behavioral and cognitive intervention. We propose a clinical framework that integrates cognitive and behavioral intervention themes.

Executive functions, self-regulation, and learned optimism in paediatric rehabilitation: a review and implications for intervention

Success for children and adults alike in educational, vocational, and social pursuits depends heavily on effective self-regulation of cognitive and social behaviour. Our goal in this article has been to summarize recent literature on executive self-regulatory functions, their importance, their development during childhood, the types of disability associated with EF impairment, and intervention approaches that have been shown to be useful for related disability groups. We also examined the literature on learned helplessness and learned optimism for clues to a comprehensive approach to helping children with EF impairment, in particular those with acquired brain injury. The central rehabilitation-relevant themes that we have derived from these reviews are: (a) although brain injury can directly impair executive self-regulation, aspects of the environment and the presence or absence of support behaviours of others can reduce or amplify the neurologic impairment; (b) interventions need to be context sensitive; (c) everyday routines of instruction and parent-child interaction are the ideal context within which to provide EF facilitation; and (d) a primary role for rehabilitation specialists is to help everyday people effectively organize and modulate their support for and everyday interactions with children with disability. In an ideal world, competent and optimistic rehabilitation professionals work collaboratively with children and their parents, teachers and others to ensure an optimistic vision of the future that includes an increasingly autonomous child with the executive self-regulatory skill needed to succeed in adult life.

Context-sensitive behavioral supports for young children with TBI: Short-term effects and long-term Outcome

Objective:To investigate the effects of a multicomponent cognitive-behavioral intervention on the challenging behavior of two young children with growing behavioral concerns after traumatic brain injury. Design:Single-subject reversal designs were used to document the effects of the intervention on the specific dependent variables. In addition, qualitative data were collected to determine the childrens long-term outcome and staff evaluations of the intervention. Participants:Both children were normally developing before injury at age 5 years. Both experienced increasing behavior problems as expectations in school escalated. Main Outcome Measures:Quantitative data included frequency and intensity of aggression and amount of work completed. Qualitative data included childrens general engagement in school work and peer interaction and staff evaluations of the intervention. Intervention:The intervention included components of positive behavior supports, cognitive supports, and an executive function routine. Results:The targeted challenging behaviors were reduced to near zero with decreased intensity. Long-term outcome was positive. Conclusions:These results illustrate the potential for successfully treating behavior disorders in young children with traumatic brain injury using a support-oriented intervention that combines behavioral and cognitive components.

Metaphoric identity mapping: Facilitating goal setting and engagement in rehabilitation after traumatic brain injury

Difficulty re-establishing an organised and compelling sense of personal identity has increasingly been identified as a critical theme in outcome studies of individuals with severe traumatic brain injury (TBI) and a serious obstacle to active engagement in rehabilitation. There exists little empirical support for approaches to identity reconstruction that address common impairments associated with TBI. Similarly, there is as yet little empirical support for theoretically sound approaches to promoting engagement in goal setting for this population. This article has two purposes. First, theory and procedures associated with metaphoric identity mapping are discussed in relation to goal setting in TBI rehabilitation. Second, the results of a qualitative pilot study are presented. The study explored metaphoric identity mapping as a facilitator of personally meaningful goal setting with five individuals with significant disability many years after their injury. Drawing on principles of grounded theory, the investigators extracted data from semi-structured interviews with clients and clinicians, from focus groups with the clinicians, and from observation of client–clinician interaction. Analysis of the data yielded five general themes concerning the use of this approach: All clients and clinicians found identity mapping to be an acceptable process and also useful for deriving meaningful rehabilitation goals. Both clients and clinicians saw client-centred goals as important. Cognitive impairments posed obstacles to this goal-setting intervention and mandated creative compensations. And finally, identity-related goal setting appeared to require a “mind shift” for some clinicians and demanded clinical skills not uniformly distributed among rehabilitation professionals.

Evidence-based practice guidelines for instructing individuals with neurogenic memory impairments: What have we learned in the past 20 years?

This article examines the instructional research literature pertinent to teaching procedures or information to individuals with acquired memory impairments due to brain injury or related conditions. The purpose is to evaluate the available evidence in order to generate practice guidelines for clinicians working in the field of cognitive rehabilitation. A systematic review of the instructional literature from 1986 to 2006 revealed 51 studies meeting search criteria. Studies were analysed and coded within the following four key domains: Population Sample, Intervention, Study Design, and Treatment Outcomes. Coding included 17 characteristics of the population sample; seven intervention parameters; five study design features; and five treatment outcome parameters. Interventions that were evaluated included systematic instructional techniques such as method of vanishing cues and errorless learning. The majority of the studies reported positive outcomes in favour of systematic instruction. However, issues related to the design and execution of effective instruction lack clarity and require further study. The interaction between the target learning objective and the individual learner profile is not well understood. The evidence review concludes with clinical recommendations based on the instructional literature and a call to clinicians to incorporate these methods into their practice to maximise patient outcomes.