Addressing Meta-Cognition and Executive Function in Patients with

Traumatic and Acquired Brain Injury:

An Overview of Assessment and Treatment Approaches
Dani Goddard, OTS, CCLS
School of Occupational Therapy, Touro University Nevada, Henderson, Nevada, 89014

Abstract

Treatment Approaches

Evidence indicates that there are many

negative functional implications which can
result from acquired and traumatic brain
injury, especially when meta-cognition and
executive function are impacted. Decreased
deficit awareness and problems with
executive functioning may make a patient
unsafe to live or work independently even if
he or she appears functionally competent
while completing basic activities of daily
living.
Retrieved from http://www.nursingcenter.com/pdf.asp?AID=828299

While an in-depth chart review may provide

the therapist with a broad overview of what to
expect from the patient based on the injury
location and severity, further evaluation and
assessment is needed in order to identify
specific functional and cognitive deficits. It is
important for occupational therapists to
address basic cognition, insight and selfawareness, ADL and IADL functionality, and
community re-entry across the continuum of
care. All of these areas and their related
occupations can be greatly affected by metacognitive and executive functioning deficits in
patients with acquired and traumatic brain
injuries.

Treatment Progression

Screening Tools & Assessments

Basic Cognition:
Mini Mental State Examination (MMSE)
Montreal Cognitive Assessment (MoCA)
Trail-Making Test (oral version), COWAT
(letters F/A/S), & CLOX 1 & 2
FIM-Based Communication/Cognition
Screening
Insight & Self-Awareness:
Self-Awareness of Deficits Interview
(SADI)
Mayo-Portland Adaptability Inventory-4
(MPAI-4)
ADL- & IADL-Based Cognition:
Cognitive Screen for Grooming (CSG)
Executive Function Performance Test
(EFPT)
Community Re-Entry:
Multiple Errands Test (MET)
Site-specific and community-based
scavenger hunts

References (A Partial List)

In addition to these levels of treatment,

insight and self-awareness should be
assessed continuously to evaluate metacognition as the patient progresses.

Doig, E., Kuipers, P., Prescott, S., Cornwell, P., & Fleming, J. (2014).
Development of self-awareness after severe traumatic brain injury
through participation in occupation-based rehabilitation: Mixedmethods analysis of a case series. American Journal of Occupational
Therapy, 68(5), 578-588. doi: 10.5014/ajot.2014.010785
Kennedy, G. J., & Smyth, C. A. (2008). Screening older adults for
executive dysfunction. The American Journal of Nursing, 108(12), 6271. doi: 10.1097/01.naj.0000341886.15318.20

Task-Specific Training:
Occupationally/functionally based and meaningful, repetitive practice, spaced
retrieval of information (graded as memory improves), dual task training as
appropriate (increases divided attention and working memory)
Metacognitive Strategies:
Cognitive Orientation to Daily Occupational Performance (CO-OP Approach)
Goal, plan, do, check: planning should be facilitated by therapist; can use
COPM-based format to set goals
Predict and evaluate
Error-free Learning:
Break down the targeted task into small, discreet steps
Provide demonstration until patient is able to return demo properly
Encourage patient to avoid guessing and ask for assistance if needed
Correct errors immediately
Carefully fade prompts (verbal, tactile, and physical)
Chaining (forward, backward)

Sample Interventions
Create a memory book or daily log to help patients keep up with therapy sessions
(schedule, goals, interventions, and plans), visits from loved ones, or other events
Practice shopping online, paying bills; provide budgets and needed tools like a
balance register or calculator (or encourage patient to use tools on his/her phone)
Acquire a bus schedule/route map and plan a trip using public transit
Help the patient use social media, email, or text messages appropriately to
communicate with family and friends (or find online peer support groups)
Write a note or post card, address it, and send it in the mail
Print out a menu online, give the patient a budget, and have the patient choose a
meal (including beverage, appetizer, and dessert); have patient total amount and
calculate tip (ideally, take the patient out to a restaurant to practice first-hand)
Plan a meal, use the internet to search for a recipe, create a shopping list, then
cook the meal (have the patient do all steps except grocery shop, unless applicable)
Review home safety scenarios and emergency protocols
Play memory or categorization games such as Simon, Scattergories, or The Game
of Things (free online word category games are also available)
Use a map to plan a day trip or sequence outings
Learn how to use a navigation app on a cell phone or online for printed directions
Teach a novel sequence of exercises/steps to a task (patient return demonstrates)
Use newspaper or online resources to check weather, sports, or current events
Complete small fix-it tasks (i.e. install batteries and set a portable alarm clock)
Unload dishwasher and sort utensils/put away dishes in the proper place
Help patient set up medication sorter before discharge
Walk to a store to make a small purchase (book, magazine, snack, gift for a loved
one); set a budget beforehand and see if the patient can recall and follow limit
Utilize digital apps such as Lumosity, Flow Free, and Brew the Word to address
specific cognitive deficits; may also use apps to address memory, schedules, etc.