How To Improve Executive Function in Adults: Mild to Moderate

Your patient with executive functioning deficits (post brain injury) is out of the acute phase and ready to up their game!

Maybe they’ll be home with less caregiver support. Or even returning to work or school. In this new phase, how can speech therapy help increase independence and quality of life?

In this post, you’ll find treatment ideas for how to improve executive function in adults with mild to moderate deficits.

For problem-solving worksheets and handouts, check out The Adult Speech Therapy Starter Pack!

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• Executive Functioning Strategies for Adults
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How To Improve Executive Function In Adults

When treating executive functioning, you’re teaching a patient how to better solve problems and gain control of their behaviors and emotions.

You do this to help patients be more independent in successfully making, planning, and executing their goals.

So where do you begin?

First, we must understand the executive functioning strategy. This evidence-based strategy is the foundation of all executive functioning treatment.

The Executive Functioning Strategy

We turned this evidence-based, cognitive rehab strategy into a patient and SLP-friendly worksheet called the Game Plan Worksheet.

Download our FREE Executive Functioning Worksheets bundle, which comes with long and short versions of the Game Plan Worksheet, plus a bonus Self-Awareness Worksheet.

The executive functioning strategy:

1. My Goal. The patient sets a goal
2. My Plan. They plan the steps to achieve that goal, including anticipating obstacles and solutions
3. Do The Task. They problem solve how to be organized and motivated enough to initiate and complete the task
4. How Did I Do? They reflect on how they did

The 3 Steps To Teaching Strategies

1. Acquisition
   • First, teach the patient how to use the strategy
   • Print out the Game Plan Worksheet (and Self-Awareness worksheet, if needed) and model how to use it
     
2. Application
   • Next, the patient tries the worksheet with a task you know they’ll succeed at
   • This increases confidence and buy-in
   • Gradually increase the challenge and functionality of the task
     
3. Adaptation
   • Teach your patient how to use the strategy outside of therapy (including homework)
   • Work on internalizing the strategies to teach how to problem solve without the worksheets
   • One way to transition your patient from external help (i.e. worksheets) to an internal skill is through Self-Talk

Self-Talk in Executive Functioning Treatment

1. Have the patient talk themselves through a task while using a visual aid
   • “The Plan” section of The Game Plan Worksheet. “First I will__, then I will____, finally I will___.”
2. Work towards doing the task with self-talk and without the visual aid
3. Work towards fading self-talk into whispering the steps
4. Work towards fading whispering into inner talk of the steps

The ultimate goal of self-talk is generalization: Your patient uses this strategy throughout the day to improve executive functioning.

How to Cue In Executive Functioning Treatment

Try the Pause-Prompt-Praise method of verbal cueing and feedback.

1. Pause
   • When the patient makes an error, pause the task without pointing out the error. See if they self-correct
2. Prompt
   • If the patient doesn’t self-correct, give a non-specific prompt. For example, “That wasn’t quite right”
   • If the patient still doesn’t self-correct, give a specific prompt. For example, “You skipped step #3”
3. Praise
   • Praise any attempts to recognize and correct errors

When appropriate, add in video feedback. Research shows that watching themselves do a task helps patients improve self-awareness.

Executive Functioning Activities: Mild To Moderate

The following are activities to treat mild to moderate executive functioning deficits, post brain injury. These are for patients who are ready for greater independence with more complex tasks at work, school, and home.

If these tasks seem too hard for your patients, see 22 Executive Functioning Tasks for ideas to treat moderate to severe deficits.

Choose treatment goals that are important to your patient. If the goal solves a major pain point or is very motivating, your executive functioning treatment will have much better results.

Be sure to ask and listen in order to understand what these motivating goals are. Adapt the activities below to make them a great fit for each patient!

1. Improve My Environment

Choose one of the patient’s environments. Let’s use the example of a home office for someone who struggles to manage their monthly bills. If you’re in a clinic, you may choose to recreate a less-than-optimal office environment to practice the executive functioning strategy (clutter, noisy, etc.)

A goal may be to “Focus better when paying bills at my desk every month.”

Use the Game Plan Worksheet to help the patient problem solve how to focus better at their desk. This may include:

• Removing distractions
  • Close the door, turn off their phone, clear clutter, close the blinds, etc.
• Adding supports
  • Noise-canceling headphones, a timer (if distracted by using a cell-phone), asking a partner to keep the kids busy, weekly alert to pay bills
• Organize their space
  • Have a bin dedicated only to bills
  • Create a bill-paying checklist to keep track of: where to start, the exact steps to take, and when the task is done
  • Introduce apps or physical calendars and planners, as appropriate

Other Improve-My-Environment Activities:

• Organize Work Email
• Organize Backpack

2. Get A Quote

Practice getting a quote for a service that’s important to the patient. Let’s use the example of finding a new dentist for a patient who’s been putting off needed dental care.

A goal may be to “Find a dentist who takes my insurance.”

Use the Game Plan Worksheet to help the patient problem solve how to meet this goal. Example tasks are:

• Read Google or Yelp Reviews to choose 3 local dentists. Call each dentist to check if they take their insurance and to get a quote. Decide which dentist is their top pick. Call that dentist to make an appointment.
• Call their dental insurance company to get the names of 3 local dentists who take their insurace. Call each dentist for a quote. Decide which dentist is their top pick. Call that dentist to make an appointment.
• Text their local family and friends until they have 3 dentist recommendations. Call each dentist to check if they take their insurance and to get a quote. Decide which dentist is their top pick. Call that dentist to make an appointment.

Other Get-A-Quote Activities:

• Lawncare
• Petsitter
• Car repair
• Restaurant wait time
• Mental health provider
• Google Flights

3. Pack For A Trip

Practice packing the right items for a trip. If you’re in the clinic setting, have items to choose from. For example, clothing for different seasons, more or less formal clothing, etc.

A goal may be to “Pack a carry-on bag for my brother’s wedding in Hawaii.”

Use the Game Plan Worksheet to help the patient problem solve how to meet this goal. You may also vary the scenarios—using trips that are either coming up or are on their wish list. Example tasks are:

• Carry-on only
  • Size and weight of the bag, prohibited items (toiletries more than 3 ounces, pocket knives), fitting everything they need, etc.
• Business trip
  • Formal clothing, work tools (laptop, charger, presentation), makeup, etc.
• Traveling with kids
  • Car seats, medications, diapers, entertainment, etc.

4. Virtual Reality!

Virtual reality is an evidence-based executive functioning treatment activity! Multiple studies have shown that VR can improve problem solving and everyday executive functioning for patients with executive functioning deficits.

When possible, choose virtual reality tasks that directly practice the patient’s goal area. For example, a virtual supermarket to support independent grocery shopping.

The authors of Available Virtual Reality-Based Tools for Executive Functions: A Systematic Review, recommend the following functional and evidence-based VR tools (see the article for more details):

Virtual Reality: Shopping

• Virtual Multiple Errands Test
• Virtual Environment Grocery Store
• Adaptive Four-Item Shopping Task
• Virtual Action Planning – Supermarket
• Virtual Supermarket Shopping Task
• VMall
• NeuroVR Supermarket

Virtual Reality: Office

• Jansari Assessment of Executive Function
• Assessim Office

Virtual Reality: Kitchen

• VR-Cooking Task
• Therapeutic Virtual Kitchen
• EcoKitchen
• Kitchen and Cooking

Virtual Reality: City Environment

• Virtual Library Environment
• Multitasking in the City Test

Virtual Reality: Apartment Environment

• Virtual Reality Day Out-Task
• Edinburgh Virtual Errands Test

Virtual Reality: Classroom

• Virtual Classroom

The article above also lists quite a few evidence-based Virtual Reality cognitive tests and Virtual Reality games. Read the article for details.

Speak with your supervisor about buying a VR device for your workplace. Summarize and forward the literature, if you think it will help your cause!

5. Make & Follow A Checklist

Practice making and following a checklist to help solve a problem in the patient’s life. Let’s use the example of car maintenance for a patient who values (but struggles to follow through with) do-it-yourself car maintenance.

A goal may be to “Follow a car maintenance checklist every month.”

Use the Game Plan Worksheet to help the patient problem solve the steps, likely obstacles, and solutions to those obstacles of monthly car maintenance. Example steps to The Plan may be:

• Make a checklist
  • Find the right source (car owner’s manual, a reputable blog, etc.)
  • Organize the checklist (prioritize based on time, budget, etc.)
  • Make the checklist
  • Don’t lose the checklist (laminate and post in the garage, write it on a Notes app, etc.)
• Follow the checklist every month
  • Set an alarm reminder
  • Invite a friend to help keep them on track
  • Organize tools
• Buy needed supplies
  • Make a shopping list (oil, fluids, lightbulbs)
  • When to call a mechanic

Other Make-A-Checklist Activities:

• Study Guide for a Test
• Get Out of the House On Time
• Meal Planning
• Clean A Room
• Taking & Refilling Medications

6. Attend A Zoom Call

Practice attending a Zoom call for patients who need and/or want this skill. Let’s use the example of a patient who needs to attend regular Zoom calls at work.

A goal may be to “Attend work Zoom calls on time.”

Use the Game Plan Worksheet to help the patient problem solve the steps, likely obstacles, and solutions to those obstacles in attending a Zoom call. Here are example steps to be problem solved:

• Remember a Zoom meeting
  • Put meeting link, date, and time in a calendar
  • Set alerts 1 hour before and 15 minutes before the meeting
  • Make sure the app is downloaded and easy to find
• Get on the Zoom call
  • Know how to update Zoom (or save updates for later)
  • Know how to mute/unmute self
  • Know how to blur the background
  • Know how to ask questions

Other Helpful Tech Activities

• Telehealth Calls
• Decrease Tech Distraction (apps like RescueTime, OffTime, etc.)
• Organize Digital Files (computer desktop, Google Drive, etc.)
• Keep Track of Passwords
• Trustworthy Online Sources vs Misinformation

Read the 12 Best Apps for ADHD for more higher-level organization ideas. Although geared towards adult ADHD, they all support better executive functioning.

More Speech Therapy Resources

Visit our shop for print-and-go worksheets, handouts, goals banks, and much more!

References

• _{Aparo, M., & Brewer, C. H. (2022, September 27). 7 Executive Functioning Strategies for Adults PDF. Adult Speech Therapy. Retrieved March 17, 2023, from https://theadultspeechtherapyworkbook.com/executive-functioning-strategies-for-adults/}
• _{Borgnis, F., Baglio, F., Pedroli, E., Rossetto, F., Uccellatore, L., Oliveira, J. A., Riva, G., & Cipresso, P. (2022). Available Virtual Reality-Based Tools for Executive Functions: A Systematic Review. Frontiers in Psychology, 13. https://doi.org/10.3389/fpsyg.2022.833136}
• _{Cicerone, K. et al.(2019). ACRM Cognitive Rehabilitation Manual & Textbook Second Edition. American Congress of Rehabilitation Medicine. https://acrm.org/meetings/cognitive-rehab-training-second-edition/}
• _{Jacoby, M., Averbuch, S., Sacher, Y., Katz, N., Weiss, P. L., & Kizony, R. (2013). Effectiveness of executive functions training within a virtual supermarket for adults with traumatic brain injury: a pilot study. IEEE transactions on neural systems and rehabilitation engineering : a publication of the IEEE Engineering in Medicine and Biology Society, 21(2), 182–190.}
• _{Jeffay, E., Ponsford, J., et al. (2023). INCOG 2.0 Guidelines for Cognitive Rehabilitation Following Traumatic Brain Injury, Part III: Executive Functions. Journal of Head Trauma Rehabilitation, 38(1), 52-64. https://journals.lww.com/headtraumarehab/Fulltext/2023/01000/INCOG_2_0_Guidelines_for_Cognitive_Rehabilitation.5.aspx}
• _{Schmidt, J., Fleming, J., et al. (2013). Video feedback on functional task performance improves self-awareness after traumatic brain injury: A randomized controlled trial. Neurorehabilitation and Neural Repair, 27, 316-324.}
• _{Tyler, A. (2020). Thriving with ADHD Workbook for Teens: Improve Focus, Get Organized, and Succeed. Callisto Media.}