Executive dysfunction is one of the most complex and impactful cognitive impairments following a traumatic brain injury (TBI). In occupational therapy, understanding and treating executive function deficits is vital for restoring independence in daily life. This article explores a fictional but realistic case scenario of a client recovering from moderate TBI, highlighting the occupational therapy process from assessment to intervention.
Case Summary
Client: John, 35-year-old male graphic designer
Diagnosis: Moderate Traumatic Brain Injury (TBI) sustained in a motor vehicle accident
Living situation: Temporarily residing with parents after previously living independently
Functional Challenges
- Difficulty planning and organizing tasks (e.g., meal prep, finances)
- Trouble initiating and completing daily routines without cues
- Misses appointments; struggles with time management
- Poor adaptability in unfamiliar or unpredictable situations
- Impaired self-awareness of cognitive limitations
Despite observable deficits, John maintains that he is functioning normally and expresses eagerness to return to work, revealing a gap in self-awareness.
Occupational Therapy Goals
- Enable the successful planning and execution of multi-step functional tasks using compensatory strategies.
- Promote independent initiation and completion of structured routines.
- Enhance self-monitoring during tasks to support error recognition.
- Increase intellectual, emergent, and anticipatory awareness.
- Apply learned strategies to real-world contexts, especially work-related tasks.
Step-by-Step OT Intervention Plan
1. Comprehensive Assessment
- Informant Interviews: Collect input from John and his parents using interviews or tools like the BRIEF-A (Behavior Rating Inventory of Executive Function—Adult Version). This helps detect discrepancies in perceived functioning.
- Performance-Based Testing: Use the Executive Function Performance Test (EFPT) to assess functional task execution (e.g., bill paying, meal prep, medication management).
- Dynamic Assessment: Evaluate how John responds to graded cues and task modifications. This reveals learning capacity and optimal support strategies.
- Informal Observation: Monitor behaviors such as distractibility, poor task sequencing, or lack of goal-directed activity during therapy.
2. Targeting Executive Function in Intervention
- Planning & Organization: Teach structured problem-solving (goal setting, planning steps, evaluating outcomes). Integrate external aids: planners, lists, and visual schedules.
- Task Initiation: Use environmental triggers (alarms, color-coded reminders) and structured routines to support action onset. Gradually reduce external prompting.
- Self-Monitoring: Encourage predictions before tasks and reviews afterward. Use video feedback or therapist-guided reflection.
- Generalization: Increase complexity and novelty in tasks over time to improve adaptability. Practice in varied environments (clinic, home).
3. Addressing Self-Awareness
- Performance Feedback: Use real-task outcomes to highlight gaps in John’s anticipatory and emergent awareness.
- Report Comparisons: Facilitate discussion around differences in John’s self-assessment vs. caregiver reports.
- Supportive Challenge: Use therapeutic tasks that ensure both successes and manageable failures to build insight without discouragement.
4. Integration Into Daily Life
- Meaningful Activities: Help John practice strategies in tasks related to graphic design or managing personal projects.
- Environmental Support: Train family members to provide the right level of assistance based on John’s needs and progress.
- Emotional Monitoring: Address frustration, withdrawal, or resistance that may emerge as awareness increases.
Conclusion
Executive dysfunction affects far more than abstract thinking; it disrupts independence, safety, and self-identity. Through performance-based assessments, structured interventions, and an emphasis on metacognitive awareness, occupational therapists can support clients like John in regaining functional control over their lives. This case demonstrates the importance of addressing not just cognitive impairments, but also the client’s self-perception, environment, and emotional readiness to engage in meaningful change.
Note: This case scenario is fictional and was generated using AI tools (Notebook LM) for educational purposes, grounded in evidence-based occupational therapy (OT) practices.