Novakovic-Agopian, T., Abrams, G., Chen A., Carlin, G., Burciaga, J., Loya, F., Madore, M., Murphy, M., Lau, K., Mayer, C., Kornblith, E., Marton, K., & Rodriguez, N. (2015). Executive function training in veterans with chronic TBI: short and longer term outcomes. San Francisco VAMC, VA NCHCS in Martinez, University of California San Francisco and Berkeley.

1. Long Term Follow-up
(6ms-2yrs post training)
Neuropsychological Assessment Performance
Complex Attention & Executive Functions
Complex Functional Task Performance
Goal ProcessingScale (GPS)
Emotional Adjustment Self-Assessment of Emotional
Adjustment / Regulation
Profile of Mood States
Conclusion
Consistent with the results of the pilot study (Novakovic-Agopian ,
2011), preliminary results indicate that post GOALS training
participants significantly improved on neuropsychological
measures of attention/executive function, complex functional task
performance, and indicated improvements in emotional adjustment
and daily functioning. At the time of the follow-up, conducted up to
2 years post training, participants maintained most of these gains.
Preliminary results suggest that GOALS training may improve
cognitive functioning with ecologically significant impacts for
Veterans with chronic TBI and executive dysfunction. Furthermore,
improving executive control functions may also improve
functioning in other domains, such as functional performance in
daily lives and emotional health. Intervening to improve cognitive
functioning may be valuable even during chronic stages of injury.
Executive Function Training in Veterans with Chronic TBI: Short and Longer Term Outcomes
Novakovic-Agopian T., Abrams G., Chen A., Carlin G., Burciaga, J., Loya F., Madore M., Murphy M., Lau, K., Mayer C., Kornblith, E, Marton K. & Rodriguez N.
San Francisco VAMC, VA NCHCS in Martinez, University of California San Francisco and Berkeley
Support from VA Rehabilitation Research & Development
Contact: Tatjana.Novakovic-Agopian@va.gov
Introduction
Deficits in executive control processes, including selection,
maintenance, organization and execution of goal-relevant
information and activities, are some of the most disabling
consequences of brain injury. Challenges in development and
evaluation of intervention effectiveness include defining specific
targets of therapy, assessing change in functioning at different
levels, as well as maintenance over time.
Goal-Oriented Attentional Self-Regulation (GOALS) is an executive
function training designed to target deficits in executive control
processes with training in attention regulation applied to
participant-defined goals. In an initial study individuals with chronic
acquired brain injury significantly improved post GOALS, but not
post brief control intervention, on measures of: attention/executive
function and memory, functional task performance, and goal-
directed control over neural processing on fMRI (Novakovic-
Agopian, Chen et al 2011; Chen, Novakovic-Agopian et al 2011).
The objective of this ongoing study is to assess the short and long
term effectiveness of GOALS in Veterans with chronic TBI and
executive dysfunction.
Interventions
The GOALS training focuses on:
• Attention regulation skill building
• Applying attention regulation and problem solving strategies
to participant-defined goals/projects and daily life
Participants and Methods
Thirty Two Veterans with a history of chronic TBI (6+months)
completed a training program consisting of 5 weeks of GOALS
training, and 5 weeks Brain Health Education (EDU) comparison
training. All participants were on a stable medication regimen and
had residual mild to moderate functional deficits, including an
evidence of dysfunction in frontal executive functions. Evaluators
were blinded to intervention assignment
Results
Post Training
Neuropsychological Assessment Performance
Complex Attention & Executive Functions
Consistent with the results of the pilot study, participant’s
performance significantly improved on measures of complex
attention and executive function post GOALS, but not post EDU
training.
Complex Functional Task Performance
Goal ProcessingScale- (GPS)
Post GOALS training participants performance significantly
improved on the: Overall GPS Performance, as well as on Planning,
Self-Monitoring, Maintenance of attention, Switching of Attention,
Task Execution, and Memory subdomains. Post EDU training there
was no significant change in performance.
Emotional Adjustment
Self-Assessment of Emotional Adjustment / Regulation
Profile of Mood States
Post GOALS training participants indicated significant decrease
POMS Total Mood Disturbance summary score, and in sub-scores of
Confusion, Tension, Depression, and Anger. Post EDU training there
were no significant changes.
Suppression
of non-relevant
processing
Sources of
cognitive noise
Internal
External
Goal-directed
information
processing
Selection of
Goal-Relevant
Information
GOALS Session Outline
Session 1 Introduction and overview
Session 2 Absentmindednessand mindfulness
Session 3
Progressive information maintenance:
Mindfulness exercices
Session 4
Goal selection:
Discuss options for group and individual projects
Session 5
Breaking down projects into sub-tasks, creating timeline.
Apply to group and individual projects
Session 6 Execution and dealing with procrastination
Session 7 Staying on tasks, error correction and adjustments
Session 8 Project progress review and adjustments
Session 9 Individual projectpresentation
Session 10 Group project presentation and graduation celebration
AppliedMindfulnessBased
AttentionRegulation
AppliedGoalManagement
Baseline Weeks 1 - 5 Weeks 6 - 10
Follow-up
6 – 24 Month
Group 1
GOALS Training:
23 hour
group/individual
20 hour homework
Self maintained
practice
Self maintained
practice
Group 2
EDU Training
23 hour
group/individual
20 hour homework
GOALS Training:
23 hour
group/individual
20 hour homework
Assessment1
Assessment2
Assessment3
Brain Health Education - EDU
Control intervention matching GOALS
in therapist time and intensity
Session 1 Introduction and Basic Brain Anatomy
Session 2 Neuroplasticity
Session 3 Movement, Vision and Language
Session 4 Memory
Session 5 Attention and Executive Functions
Session 6 Sleep and the Brain
Session 7 Diet and Physical Activity and the Brain
Session 8 Stress and the Brain
Session 9 Emotions and the Brain
Session 10 Social Bonds and the Brain/ Lessons Learned
Neuropsychological Assessment
Complex Attention and Executive Function
Working Memory
Letter Number Sequencing
Auditory Consonant Trigrams
Sustained Attention
Digit Vigilance–time & errors
MentalFlexibility
Design & Verbal Fluency Switching
Trails B
Stroop Inhibition /Switching- time & errors
Inhibition
Stroop Inhibition –time & errors
Learning and Memory
Hopkins Verbal Memory Test - Revised Brief Visual Memory Test- Revised
Functional Performance
Complex Functional Task Performance
Goal Processing Scale (GPS)
Self-Assessment of FunctionalPerformance in Daily Life
Mayo Portland Adaptability Inventory (MPAI)
Goal Processing Questionnaire (GPQ)
Emotional Adjustment
Self-Assessment of EmotionalAdjustment / Regulation
Profile of Moods States (POMS)
Beck DepressionInventory II (BDI II)
Post-Traumatic Checklist-Military (PCL-M)
79% (22/28) completed structured interview
68% (19/28) completed assessments
91% (20/22) participants reported continuing to use some of
trained strategies in their daily lives:
• Stop Relax Refocus
• Stop and review one’s work
• Prioritize daily tasks / Break larger tasks into subtasks
45% (10/22) reported returning to competitive work, as
compared to 23% (5/22) prior to training.
Assessment4