Executive Skills and Brain Injury - Dealing with the Unexpected

Neuro OT – Executive Skills and Brain Injury - Dealing with the Unexpected

Dealing with unexpected events forms part and parcel of our daily routine. Our lives are full of surprises; some of these surprises are welcome and bring unexpected joy; others are not so welcome, such as a life-changing accident or illness. This week I have been reflecting on how we manage unexpected events and how, in general, we have the skills to overcome many scenarios during a week.

Our executive function plays a major role in how effectively we deal with new experiences or problems. For a client with brain injury, limitations affecting executive functions can significantly impact an individual’s ability to achieve goals and live successfully and independently. The topic of my article this week has come about because of a traumatic incident on the London Underground.

Our Executive Functions in Action

I was using the London Underground to get to a meeting that I had arranged some months before. I was sat on the train when I became aware of a disturbance at the other end of the train. A seven-year-old boy, excited to be in London during the summer holidays, had jumped aboard the train minus his parents, who were left standing on the platform. Obviously, the situation was very stressful for the boy, even more so when the doors closed and the train started to pull away. The boy was distressed and had no idea how to help himself or get back to his family.

My initial thoughts were one of uncertainty, should I be the one to act, or would someone else step into that role? These thoughts were swiftly followed by a compulsion to act to help the boy, particularly as no one else appeared keen! Some internal anxiety and personal dialogue surrounded the action. The boy did not know me; how would he react? I felt out of my comfort zone, anxious for the boy who was so obviously distressed and unsure what to do for the best.

My brain launched into action; I used my executive function to control and regulate my behaviour. I needed to manage my actions within a time-sensitive situation successfully. My first action was to ask the other commuters for help and advice; given my choices impacted another human being, I needed to seek assurances that my actions were correct and appropriate.

Memory and Decision Making

I used my stored knowledge, previous memories and experiences to aid my decision making and weigh up the potential consequences of my actions. I took information from the environment and responded accordingly, managing my time, paying attention, and switching focus automatically. All this information helped my brain to evaluate the situation, function under pressure and act. This all happened in a matter of minutes. I was using my ‘executive functions’.

Executive function is our ability to ‘organise’ our environment from the information our brain receives and ‘regulate’ our behaviour and response to our surroundings. For example, seeing a broken electrical appliance and a frayed plug is likely to cause anxiety. This is where our brain uses our executive function to help us decide how to act next. The organisational part of the executive function reminds us that exposed wires are dangerous, and the regulatory element recognises that touching live wires will leave us exposed to injury or death.

Brain Injury and Executive Function

Impairments with our executive function following brain injury can have a significant impact on functional independence. These limitations can have significant consequences for clients with a hidden disability or ‘minor’ brain injury. The workplace environment, for example, places an increased level of demand on our skills due to the nature of the work undertaken, especially concerning new, multiple or unfamiliar activities.

Our executive function is a set of mental processes that help to connect past experience with present action. It enables us to plan, organise, problem-solve, make decisions, remember details, and manage our time and space during activities. Our brain’s executive function ensures we ‘do’ in a safe and efficient manner. At a basic level, it helps us work out how to wire a plug effectively and, on the other hand, will get us out of potentially unsafe situations even when we are experiencing heightened levels of emotion.

When I think about the young boy, he was obviously distressed; he appeared to be in shock and was helpless. He did not have the necessary skills or past experiences to guide his decision making; in effect, he was unable to help himself. His brain was overwhelmed by emotion, so he could not plan a way back to his family.

Our brain continues to mature and develop connections and skills well into adulthood. As we mature our executive functions are shaped by physical changes in the brain and by life experiences, or what we learn and experience at home, in school and the world at large.

The Role of the Neuro OT and Executive Function

As neuro occupational therapists, we use therapeutic strategies and interventions with adults, children and young people to develop efficient executive skills during daily tasks. As parents, we often act as a coach and mentor, helping our children develop the skills needs for adulthood while trying to keep them safe.

Problems with executive function can be supported by several external strategies, including:

• Use of visual prompts and aids within the environment to support executive skills and memory.
• Adopting an organised and structured approach to activities. Many clients with significant difficulties benefit from functional scripts that incorporate visual and written aids.
• Structured routine that considers a plan for transition periods and unexpected activities and events.
• Introduction of prompts and guidance that assist with developing a view on time, including estimating how long an activity should take, goal setting for long- and short-term goals, including timelines for short- and medium-term projects and activities.
• Conducting an activity analysis to break down individual components into achievable steps.
• Utilising smart technology in the form of apps, diaries, alarms, calendars and reminders.

The impact of the environment should not be ignored; structure and organisation of the workspace are important; consider separate areas for different activities, minimise clutter and consider a weekly task of cleaning and rearranging working space for the week ahead.

Thankfully, on the London Underground that day, my executive function did not let me down. The decisions I made and the actions I took, using my executive function, matched his mum and the British Transport Police. We all decided, independently of each other, that meeting at the next station would be the most sensible option. The boy was very relieved to be reunited with his mum but not quite as relieved as she was to see him!

Further reading:

Hidden disability, hidden ability

Acquired brain injury and complex behaviour in the community setting