Treatment of Post-TBI Executive Dysfunction: Application of Theory to Clinical Practice

Past Studies

Past Studies have shown that after TBI difficulties with executive functions (known as executive dysfunction) result in increased disability and can act as a barrier to successful participation in community living for individuals with TBI. However, most previous research about ways to improve executive dysfunction has not adopted the most vigorous research methods. For example, some have studied only one or a small number of participants1. Additionally, very few studies have adopted what many scientists consider the most exacting standards for testing, namely randomized clinical trials (RCTs), in which participants are assigned to differing treatment options (sometimes including no treatment) without telling them which option each person will receive. This type of research is valued because it avoids the danger of a person improving just because he or she expects to – hope and belief can be very powerful “medicines”. Using RCT methods, one is able to tell if improvements are truly due to the treatment or are more likely due to the participant’s getting better for reasons that may have nothing to do with the treatment.

Prior studies are useful in that they have explored a variety of strategies to address problems in executive functioning. Some have focused on methods to improve problem-solving abilities in which participants are trained to take a series of steps when they encounter problems in daily life, that is, recognize that a problem exists, stop to focus on it, identify different ways to solve the problem and evaluate what works best in solving the problem. Other studies have targeted treatment efforts on ways to improve a person’s ability to pay attention. Some research has explored learning to problem solve when dealing with problems in real-life situations, in contrast to just practicing skills in the “classroom”.

While a number of different ways to treat executive dysfunction have been studied and a variety of methods have been used, no real agreement exists in the field – persuasive evidence is lacking – about how to help people with post-TBI difficulties in this aspect of functioning.

This Article

This Article describes the creation of a model of treatment for executive dysfunction. It is based on several theories, which not only help shape the treatment methods but also direct researchers to look in specific places for the effects of treatment.

Based on the model, as well as results of prior research, a day treatment program called the Executive Plus Model was designed and is being tested currently. A second program was also developed – a standard day treatment program – as a point of comparison. Using what is known as a “top-down structured approach,” the Executive Plus Model is based on participants learning and using a single strategy to solve problems in a number of different situations. It also focuses on training participants to pay better attention in all situations, as a necessary element to bring into problem solving. The third element of Executive Plus is a focus on regulating emotions, another critical ability that supports improved problem solving.

The authors describe the conduct of a study in which participants are assigned randomly to the Executive Plus day treatment program or to the standard day treatment program. Participants in the study will be persons who sustained a TBI at least three months before they begin the program, who have problems in executive functioning, who are living in the community and can read at least at the 6th grade level.

Who May Be Affected By These Findings

Although this article is preliminary – describing how theory shapes a specific research activity – when the study described is completed, individuals with TBI will benefit from having stronger evidence of “what works” in treating executive dysfunction. Researchers can benefit from the strategies and methods described.

Caveats

Limitations include the fact that the proposed randomized clinical trial can only test the impact of Executive Plus overall; the design will not answer more detailed questions, for example, Is the attention training component useful? Who benefits most from the emotional control training?

Bottom Line

The research model described in the article is intended to provide better answers about what works and what doesn’t to help people improve executive functioning after TBI.

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