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

lpowell@uoregon.edu

541-346-0572

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