problem solving in everyday life following brain injury: current research
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Problem Solving in Everyday Life Following Brain Injury:
Current ResearchLaurie Ehlhardt Powell, PhD, CCC-SLP
Center on Brain Injury Research and Training
University of Oregon
Coastline Community College - Brain Injury Research Symposium
Tuesday, May 13, 2014
Thanks for inviting me
What is CBIRT?• Research center at University of Oregon
• Established in 1993
• Focus: Conduct research and training to improve the lives of children and adults with TBI
Funders: National Institute of Disability and Rehabilitation Research (NIDRR); Health Resources Service Administration/Maternal and Child Health—TBI Program; National Institute of Child Health and Human Development; Oregon Department of Education
CBIRT team
In this presentation, attendees will learn about:
• current research re: problem solving interventions following brain injury.
• systematic instructional techniques that can support improved problem solving.
• a prototype, integrated model for supporting problem solving.
Following brain injury…
What is problem solving?
“Problem solving is a higher-order cognitive activity that arises in situations for which no response is immediately apparent or available.”
(Rath, Hadril, Litke & Diller, 2011; pg. 320).
Common Problem Solving Steps
1. Is there a problem?
2.What is the problem?
3.What are possible solutions to the problem?
4.Which solution(s) will I try?
5.How effective was the solution(s)?
What goes into problem solving (PS)? Examples
Attention-Awareness
Speed of processing
Focus; Is there a problem?
Taking in & keeping up with incoming information
Working memoryKeeping the problem in mind; working with it
Long-term memory Thinking back to previous experience with this or related problem
Critical thinking-Reasoning (Compare-Contrast; Divergent Thinking)
Same or different from past experience? Generate possible solutions; Compare and contrast pros vs. cons
Decision making Choosing a solution (based on what factors)
Initiation Initiating implementation of the solution
Self-monitoring; self-evaluation Evaluating how it’s going, how it went
Self-efficacy Belief or confidence in one’s own ability to effectively solve the problem
Why focus on problem solving skills
following brain injury?
• Problem solving skills are useful across a variety of situations and environments.
• Having a brain injury adds to/compounds everyday problems.
Cory’s Story ….
ContextExecutive functions: goal setting, planning, organizing, initiating, self-monitoring, problem solving) = Self-regulation
Metacognition: Thinking about your own thinking
Meta-cognitive strategy instruction (MSI)(Kennedy et al., 2008)
Meta-cognitive strategies - Examples
• Prediction-Reflection (Cicerone & Giacino, 1992)
• Goal Management Training (Levine et al., 2000)
• Time Pressure Management (Fasotti et al., 2000)
• Problem Solving Skills (von Cramon et al., 1991; Rath et al., 2003)
Research
Kennedy et al., 2008 – Meta-analysis; executive function interventions – meta-cognitive strategies; TBIStudies N = 15 studiesType: RCTs, single case experimental, case reports
Outcome: “(There is) sufficient evidence to make the clinical recommendation that MSI should be used with young to middle-aged adults when improvement in everyday, functional problems is the goal.”
Research Cicerone et al., 2011 – Literature review; cognitive rehabilitation; TBI & stroke
Studies N = 112 total; 19 focused on executive dysfunction
Type: RCTs, single case experimental, case reports
Note: Some overlap between Kennedy & Cicerone
Outcome: For those with executive function deficits - “Training in formal problem-solving strategies and their application to everyday situations is recommended during post-acute rehab after TBI.”
ResearchSpikman et al (2010); executive dysfunction; ABI
Type: RCT
Participants N=75
Intervention: 24 sessions (individual); information-awareness; goal setting-planning; initiation-execution
Control: computerized cognitive training
Outcome: Significant improvements in goal setting, planning, initiation, regulation
Research Rath et al, study - 2003; review article - 2011; group manuals (see Resources)
Type: RCT
Participants N=60
Intervention: 24 session (group); problem skills AND problem orientation (attitude; emotional self-regulation)
Control: Conventional neuropsych rehab
Outcome: Significant improvements in exec functions, self-appraisal, emotional self-regulation
Meta-cognitive strategy instruction (MSI):
What is systematic instruction?Systematic Instruction(includes, but not limited to errorless learning, spaced
retrieval)
Conventional Instruction
Limited range of instructional targets (e.g., only calendar app at first)
Broad range of instructional targets(train multiple apps)
Multiple training examples Few training examples
Mastery emphasized Mastery not emphasized
Exploration discouraged Exploration encouraged
Step-by-step models; carefully faded support
Whole task model only
High rates of correct, distributed practice and review per target
Few practice opportunities per target
Immediate corrective feedback Wait to give feedback
Training in different environments Training in clinic setting only
SI - stagesAcquisition: Learning new skills &
strategies
Adaptation: Applying (generalizing) the skills & strategies to real life contexts
Maintenance (Follow up): Making sure these “stick” for the long haul
SI & external aids
Ehlhardt, L., Sohlberg, M.M. et al. (2008). Evidence-based practice guidelines for instructing individuals with neurogenic memory impairments: What have we learned in the past 20 years? Neuropsychlogical Rehabilitation, 18(3), 300-342. (www.ancds.org; Practice Guidelines)
Gillespie, A., Best, C., & O'Neill, B. (2012). Cognitive function and assistive technology for cognition: a systematic review, Journal of the International Neuropsychological Society, 18(1), 1-19.
Related researchPowell, Glang, et al., (2012) (NIHR03HD054768)
Type: RCT
Participants N= 29
Intervention: Systematic instruction (SI) applied to PDA; calendar and task apps
Control: Conventional, trial & error instruction
Outcome: SI = better maintenance and generalization
6.62
4.25
5.07
6.86
1.67
2.29
SI applied to assistive technology for cognition (ATC)
(Ehlhardt Powell, Glang, et al., 2012)
Related researchEhlhardt Powell, Glang, et al., (in preparation) (NIDRR-H133G090227)
Type: multiple baseline across behaviors in a vocational setting
Participant N= 1
Intervention: SI applied to ATC + internal strategy training – “If I need to remember, I need to record it.” “Go home”
Outcome: Routine use device/apps at work
SI applied to ATC + MSI (Ehlhardt Powell, Glang et al in preparation)
Summary-Themes
• Research evidence
• Problem solving skills (steps) AND problem orientation (attitude; self-regulation)
• Systematic instruction: internal strategies & external supports
• Limited resources for multiple treatment sessions
• ABI heterogeneity -Severity & type of cognitive impairments
Generalizing Problem Solving Strategies to Everyday Environments
Following TBI
National Institute on Disability and Rehabilitation Research (NIDRR): H133A120149
Three-year development grant (October 2012-September, 2015)
Grantee: Center on Brain Injury Research and Training, University of Oregon; Laurie Powell, Principal Investigator
Partners: Michelle Wild, Co-Investigator; Coastline Community College, Acquired Brain Injury Program
Current status: Wrapping up development and heading into experimental evaluation phase
ProSolv Intervention Package
Improved problem solving
skills in everyday life
Client-coach partnership
Introductory on-line tutorial
Web-based mobile app
ProSolv Steps
1. What is the problem?
• in the moment vs. future
2. What do I already know about the problem?
• self-efficacy/attitude; past experience; triggers
3. What are possible solutions to the problem?
4. Which solution(s) will I try?
5. How effective was the solution(s)?
ProSolv Component #1 Client-Coach Partnership
ProSolv Component #1: Coaches’ Manual TOC
ProSolv Components #2: On-line training
ProSolv Components #3: Mobile app
ProSolv Methodology - Participants
Individuals with acquired brain injury:
Medically stable; at least 1 year post
Memory & executive function challenges
Independent using mobile technologies for phone, calendar, tasks lists, etc
Coaches:
Occupational therapists; speech-language pathologists; rehab assistants; neuropsychologists
ProSolv Methodology - Design
Years 1-2 (2012-2014): Participatory Action Research:
• “Lean Start Up” product development
• Focus groups
• Several rounds of usability testing;
Years 2-3 (2014-2015): Single case experimental study; Experimental group study
ProSolv Methodology – Outcome Measures
Ultimate Outcome? Stay tuned…ProSolv faded out = Adaptability
Questions-Discussion
See References & Resources page
Contact Information:
Laurie Ehlhardt Powell, CBIRT, University of Oregon
541-346-0572
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