Supporting Young People for Success in School and Beyond

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Supporting Young People for Success in School and
Beyond

• Tim Feeney, Ph.D.
• Project Director
• New York Neurobehavioral Resource Project
• Clinical Director
• School and Community Support Services
• Schenectady, NY USA
• tfeeney_at_scssconsulting.com

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Cant fix em, cant save em You are an
opportunity whether or not people take advantage
of that opportunity is up to them
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Chucks brain injury is different than Connors
brain injury is different than Sarahs brain
injury is different than Devans brain injury
While there are common traits, everyones brain
injury manifests itself differently, so any
intervention strategies will need to be
tailored to address these differences.
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UNIFORMITY is not necessarily a good quality in
intervention There is no single right
solution - sometimes the best you can do is keep
trying Plan A Plan B Plan C Sometimes what
works today wont work tomorrow!
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Its important to have fun with and create
opportunities for fun and to laugh a lot even in
the face of significant challenges
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Communication
Cognition
Behavior
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Behavioral Control

Academic Vocational Growth
Social Competence
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Context Relevancy How does this stuff apply
to the bigger world?
Useful Do the outcomes that were
targeting produce something useful to the
individual in long run? Desirable Does the
individual choose the outcomes for him/herself
when given the choice? Social Do the
outcomes result in behaviors that will increase
interactions with persons other than paid
staff? Practical Will the behavior be used
in real contexts without staff
support? Adaptable Is there a focus on
developing skills that can/will be used in a
number of situations and without staff?
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The Three Big Things
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When we think of your child at 22 years old we
need to think about the 3 most important things
to work on the things that, if s/he achieves,
s/hell have a meaningful life.
The 3 Things tend to cluster around these
areas Behavioral regulation/self-regulation
Friendships/social-interaction Vocational
skills/meaningful engagement Self-help skills
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A CONTINUUM OF PEOPLE SUPPORTS
Intensive Requiring direct and constant
interaction of staff to participate in, and
benefit from program
Specific Requiring direct support of staff
in order to participate in, and benefit from
specific (and defined) elements of the program
Periodic Requiring direct support of staff in
order to learn new/ difficult elements of the
program
Independent Requiring little support to
participate in the typical elements of the
program
Most Intense
Least Intense
Specialized A specific environment designed to
assist individuals to learn the majority of skills
Modified An environment developed to
assist individuals learn specific (and
defined) skills
Adapted Environmental and time modifications devel
oped to augment typical classroom routines
Typical No environmental modifications are
needed for the individual to to acquire new
skills and maintain already learned skills
A CONTINUUM OF ENVIRONMENTAL SUPPORTS
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• Executive Functioning as a target of all
  intervention
• Critical for self-regulation, social interaction,
  behavioral control, academic and vocational
  success

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EXECUTIVE FUNCTIONS

• those mental capacities necessary for
  formulating goals, planning how to achieve them,
  and carrying out the plans effectively (Lezak,
  1982)

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EF FUNCTIONAL DEFINITION

• Based on analysis of strategic action
• Self-awareness of strengths and limitations
  (whats hard to do whats easy to do)
• Goal setting
• Planning/organizing
• Initiating
• Inhibiting
• Self-monitoring and evaluating
• Strategic thinking
• Flexible shifting, adjusting, benefiting from
  feedback

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EXECUTIVE FUNCTIONS

• Routine, habitual, easy
• versus
• Non-routine, novel, hard, effortful
• Strategic thinking demands
• Working memory demands
• Inhibition of pre-potent response demands
• Maintenance of goal-directed behavior

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EXECUTIVE FUNCTIONS

• Organizing and controlling action, thought, and
  emotion in a way that is (1) not determined by
  immediate environmental events, (2) not
  determined by immediate impulse or states of the
  body, (3) not determined by the control of
  others, (4) directed toward personal goals, (5)
  while taking into account the goals and
  intentions of others

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EF UNORGANIZED LIST

• Setting and managing goals
• Planning
• Organizing
• Initiating
• Inhibiting
• Self-monitoring
• Strategic thinking
• Problem solving

• Flexible shifting
• Deliberately controlling any cognitive function
• Working memory
• Social perception
• Controlling emotions
• Learning from consequences
• Organized sense of self

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EF SYMPTOMS

• ineffective planning
• decreased flexibility/ shifting
• slowed processing
• diminished divergent thinking
• concrete thinking
• immature problem solving
• weak self-monitoring
• inefficient responses to feedback/ consequences
• reduced initiation
• dulled emotional responses

• impulsiveness
• poor social judgment
• social disinhibition
• egocentrism
• difficulty interpreting the behavior of others
• perseveration
• poorly regulated attention
• disorganization (in thinking, talking, and
  acting)
• weak goal formulation

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EF AND COGNITIONDELIBERATELY CONTROLLED

• Attention
• Memory and learning
• Organization (including discourse)
• Reading and writing

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EF IMPAIRMENTINTERFERES WITH EDUCATIONAL
VOCATIONAL SUPPORT

• Unaware -- unengaged
• Reduced inhibition impulsive cognitive and
  academic behavior
• Reduced initiation failure to use available
  skills
• Reduced monitoring failure to appreciate value
  of strategic behavior
• Inefficient response to consequences remain
  stuck

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Executive Functions and Learned Helplessness

• Learned Helplessness Core concept I have no
  control over events in my life, particularly
  negative events
• May result in
• Depression
• Passivity/apathy
• Anger, hostility, and acting out
• Combination

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Learned Helplessness and Attribution

• Negative Attribution
• Stable attribution things will never change
• Global attribution everything happens like this
  in my life
• Internal helplessness I cant do anything right

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Learned Helplessness and TBI

• Individuals who experience a world in which most
  events are out of their control show increased
  negative affect, slower problem solving, failure
  to master tasks, and persistent use of unhelpful
  strategies.
• After TBI, there is a natural tendency to remove
  opportunities for control from the person,
  risking learned helplessness (manifested as
  apathy, depression, or anger)

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Learned Optimism

• Optimism is associated with
• Effective self-regulation of behavior and
  cognition
• Initiation and maintenance of goal-directed
  behavior
• A disposition to obtain relevant information in
  order to make effective decisions and plans
• A tendency to attend to risks as problems to be
  solved rather than barriers to success

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Teaching Optimism

• Pennsylvania Optimism Program School-Based
  (Context-Sensitive) Intervention
• Teach a flexible/realistic attributional style
• Encourage describe ones behavior first, then
  identify related factors
• Teach problem-solving skills in the context of
  the academic and social curriculum
• Correct errors in social perception/cognition
• Facilitate assertiveness and negotiation
• Address cognition, emotion, and behavior as
  necessarily interdependent

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ONGOING CONTEXTUALIZED COLLABORATIVE HYPOTHESIS-TE
STING ASSESSMENT
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The Future of Assessment Contextualized
Collaborative Hypothesis-Testing
Whats the problem? (Using the two strangers in
the doorway rule)
Hypothesis Formulation (Why is s/he doing this?)
Hypothesis Selection (Begin with easiest to test
or most obvious)
Hypothesis Testing (Protocol for
experimentation Plan A - Plan B - Plan C Testing
time line)
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WHY TEST HYPOTHESES?

• Failure on any complex task is multiply
  interpretable
• Complex students can be supported in a variety of
  ways
• Test results do not necessarily indicate how best
  to achieve success on specific tasks

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COMPREHENSION FAILURE

• Cognitive lack of strategies
• EF failure to execute (e.g., initiation,
  inhibition)
• Language
• Academic
• Motivational/ behavioral

• Physical
• Sensory/perceptual
• Cognitive attention
• Cognitive orientation
• Cognitive memory
• Cognitive WM
• Cognitive organization
• Cognitive speed

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WHY COLLABORATE?

• Increase observations and experiments
• Increase compliance
• Educate family, staff, others
• EF training for student
• Show respect

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WHY IN REAL CONTEXTS?

• Inconsistency
• Validity problems of standardized testing
• Impact of setting, person, activity
• Impact of stress
• Observe real-world initiation, inhibition,
  self-monitoring, problem solving
• Observe effects of real-world supports and
  routines
• Observe support behaviors of others

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CCH-TA PROCESS

• Define problem
• Identify need for dynamic assessment
• Generate hypotheses
• Choose which (combination) to test
• Create experiments
• Implement (collaborate in context)
• Interpret
• Proceed to intervention or another test
• Continue to monitor and adjust

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• EXECUTIVE FUNCTION
• INTERVENTION

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TEACHNG THINKING

• Think (out loud) with the person
• A lot
• Interesting and important issues
• Highlight the thinking process
• Use motivating analogies, metaphors, etc
• Use external supports as needed
• Be a model of thoughtfulness
• Promote experimental orientation
• Gradually remove supports
• Help the person help others

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? Know that an event or activity will be
difficult? Establish reasonable goals (in some
cases these might be immediate)? Formulate a
plan to achieve the goal (or understand the
plan)? Initiate goal-directed
behavior? Refrain from actions that interfere
with the successful achievement of
goals? Attend to and evaluate how well they are
doing? Try another plan or strategy if things
are not going well
To Assure Long Term Success Individuals Need to
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Teaching Positive Attribution

• UNHELPFUL ATTRIBUTION
• I cant do anything well
• Teachers dont like me
• Other kids are lucky
• Sometimes I get it sometimes I dont I dont
  know why

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Teaching Positive Attribution

• HELPFUL ATTRIBUTION
• When I work hard and use my strategies, I do OK
  When I dont, I do badly
• Reading is harder for me than for other
  students, but I can get it if I give myself
  enough time and use my strategies.

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Teaching Positive Attribution Procedures

• Product Monitoring
• Framing
• Self-Monitoring
• Hero Identification
• Procedures associated with learned optimism

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EF CHECKLIST

• GENERAL CONSIDERATIONS
• Is intervention in the areas that fall under the
  heading "executive functions" structured around
  the individual's own meaningful goals?
• Is intervention infused into everyday activities?
  Are all everyday people oriented to how they can
  facilitate improved executive functions? Are all
  everyday people aware of the dangers of learned
  helplessness?
• Are everyday people aware of the strategies that
  the individual is being taught or is expected to
  use?
• Is successful performance in the areas grouped
  under this heading richly and naturally rewarded?
  Is the individual held responsible for effective
  strategic performance?
• Is the individual given ample opportunity to
  identify and solve his or her own problems (with
  guidance if necessary)?

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EF Checklist (contd)

• For individual's who are young or very concrete,
  are executive function tasks structured around
  concrete physical activities (versus abstract or
  cognitive activities)?
• Do everyday people in the environment routinely
  model expert use of executive functions?
• Is the individual given sufficient practice so
  that strategic behavior becomes automatic?
• Are everyday people in the environment supportive
  of strategic or compensatory ways to accomplish
  tasks?
• Does the individual respect a strategic or
  compensatory approach to everyday problems? If
  not, is appropriate help/counseling provided?
• Are everyday people in the individual's
  environment fully aware of possible limitations
  in the individual's executive functions (esp.,
  initiation and inhibition) so that they do not
  misinterpret behavior?

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LEVEL OF DEVELOPMENT

• Preschoolers Are preschoolers introduced to
  relevant vocabulary, including "hard/easy to do"
  "plan" "do something special" "review" "what
  works? what doesn't work?" Are they actively
  engaged in identifying what is hard and easy for
  them (esp. physical activities)? Are they
  actively engaged in identifying clever ways to
  accomplish difficult tasks? Are they richly and
  naturally rewarded for clever solutions to
  difficult everyday problems?
• Grade School Age Are grade school age children
  actively engaged in identifying what is hard and
  easy for them (including cognitive/academic
  activities)? Are they actively engaged in
  identifying clever ways to accomplish difficult
  tasks? Are they actively encouraged to seek help
  on their own when tasks are hard? Are they richly
  and naturally rewarded for clever solutions to
  difficult everyday problems? Are they encouraged
  to help each other solve problems?
• Older Students and Adults See entire checklist.

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Self-Awareness of Strengths and Needs

• Is the individual maximally engaged in
  identifying what is easy and hard to do, and what
  makes activities easy or hard?
• Is the individual given opportunities to compare
  performance when an activity is completed in a
  usual way versus when it is completed with
  special strategic procedures?
• Does the individual keep a journal in which
  strengths and needs are recorded?
• Is the individual given opportunity to identify
  strengths and needs in others, and strategic
  procedures that others may use (e.g., peer
  teaching)?
• Is the individual given appropriate informative
  feedback (e.g., peer feedback, video feedback,
  confrontational feedback if appropriate)?

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Goal-Setting

• Is the individual routinely asked to predict how
  well he will do on activities?
• Are predictions recorded in journals and compared
  with actual performance?
• Does the individual maximally participate in
  rehabilitation/special education goal setting? Is
  adequate support provided if this is difficult?
• Are intervention activities structured around the
  individual's personal goals?

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Planning

• Does the individual participate maximally in
  planning his or her intervention activities?
• Is a planning guide available, if needed?
• Does the individual begin the day by preparing a
  plan on a planning board or in a journal? Does
  the individual begin each activity by preparing a
  plan?
• Do therapy activities include attempts to plan
  meaningful complex events (e.g., parties,
  outings, etc.)?
• Does the individual participate maximally in
  long-term future planning? rehabilitation
  planning? IEP development

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Self-Initiating

• Do everyday people give the individual
  opportunities to initiate and wait an appropriate
  length of time? Are signals available to remind
  the individual to initiate activities?
• Do the activities that the individual engages in
  make appropriate demands on the individual's
  ability to initiate (e.g., board games may
  require little initiation conversations may
  require much initiation)?
• Are all forms of institutional "learned
  helplessness" avoided?
• Are prosthetic initiators available if needed
  (e.g., alarm watch, NeuroPage)?
• If initiation cues are necessary, are they
  provided as much as possible by peers versus
  staff? Is nagging avoided?

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Self-Inhibiting

• Do everyday people give the individual
  opportunities to inhibit that are realistic in
  their demands?
• Do the activities that the individual engages in
  make appropriate demands on the individual's
  ability to inhibit (e.g., unstructured and
  unfamiliar activities in a distracting
  environment require considerable inhibition)?
• If inhibition cues are necessary, are they as
  subtle as possible and provided as much as
  possible by peers versus staff? Is nagging
  avoided?

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Self-Monitoring/Evaluating

• Do everyday people give the individual
  opportunities to self-monitor and evaluate
  performance? If cues are necessary, are they
  subtle? Is nagging avoided?
• Is the individual maximally involved in charting
  his own performance? keeping a journal in which
  performance is recorded? graphing performance?
• Is the individual routinely asked to fill in a
  form regarding his own performance What Works?
  and What Doesn't Work?

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Problem Solving/Strategic Thinking

• Is the individual maximally involved in solving
  everyday problems as they arise? Are everyday
  people thoroughly oriented to the importance of
  problem solving?
• Is the individual maximally engaged in selecting
  strategies to overcome obstacles and achieve
  important goals?
• Is there an appropriate amount of external
  support for strategic thinking?
• Does the individual have a form that cues the
  appropriate kind of strategic thinking?
• Do everyday people in the environment expect and
  cue strategic performance?
• Do everyday people in the environment avoid
  learned helplessness, that is, do they resist
  solving all of the individual's problems?
• Is there consistency among staff and family
  members in how problem-solving tasks are
  presented and in the kinds of external
  problem-solving support that are provided? Is
  there consistency in reducing external support as
  the individual becomes increasingly independent
  in problem solving?