Journal of Behavioral and Brain Science, 2014, 4, 27-32

Published Online January 2014 (http://www.scirp.org/journal/jbbs)

http://dx.doi.org/10.4236/jbbs.2014.41004

Neuropsychological Rehabilitation of Executive Functions:

Challenges and Perspectives
Priscila Dib Gonalves1-4, Mariella Ometto2,3, Gabriela Sendoya3, Cristine Lacet4,
Luciana Monteiro5, Paulo Jannuzzi Cunha1-3,5
1
Interdisciplinary Group of Studies on Alcohol and Drugs (GREA), Institute of Psychiatry (IPq),
School of Medicine, University of So Paulo (USP), So Paulo, Brazil
2
Laboratory of Psychiatric Neuroimaging (LIM 21), Department of Psychiatry, School of Medicine,
University of So Paulo (USP), So Paulo, Brazil
3
Center for Interdisciplinary Research on Applied Neurosciences (NAPNA), University of So Paulo (USP), So Paulo, Brazil
4
Psychology & Neuropsychology Service, Institute of Psychiatry (IPq), School of Medicine,
University of So Paulo (USP), So Paulo, Brazil
5
Equilibrium Program, Department of Psychiatry, School of Medicine, University of So Paulo (USP), So Paulo, Brazil
Email: [email protected]

Received November 29, 2013; revised December 28, 2013; accepted January 9, 2014

Copyright 2014 Priscila Dib Gonalves et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
In accordance of the Creative Commons Attribution License all Copyrights 2014 are reserved for SCIRP and the owner of the
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ABSTRACT
Introduction: Executive Dysfunction (ED) is associated with difficulties in daily life and poor treatment adhe-
rence in individuals with neurological and psychiatric disorders. The aim of this paper is to present an update of
Executive Function (EF) Rehabilitation Techniques. Methods: We performed a comprehensive literature review
using the following keywords: executive function, mental disorders and rehabilitation in the PubMed, specific
journals and books. Results: There is evidence of improvement of EF using some rehabilitation techniques, such
as goal planning, goal management training, problem solving training, verbalization, drill and practice approach,
metacognitive strategy instruction, computer-assisted training and neurofeedback. However, impact of rehabili-
tation on daily life remains poorly understood. Conclusion: Executive Dysfunction (ED) may be remediated
and/or compensated at a certain degree by neuropsychological rehabilitation, but there is still a great challenge
in this area based on how to measure effectiveness of EF interventions on daily life. There is a need for the de-
velopment of new and/or combined techniques (i.e., pharmacological treatment, deep-brain stimulation) for a
broader impact on quality of life for patients.

KEYWORDS
Rehabilitation; Neuropsychology; Executive Functions and Board Games

1. Introduction cognitive, emotional and social skills. The EF is divided

into volition, planning, purposive action and effective
Psychiatric Disorders affect 450 million people and their
performance [2].
costs to society represent a significant impact on the total
Executive Dysfunction (ED) in Traumatic Brain Injury
Disability Adjust Life Years (DALYs) of all diseases in
the world [1]. One of the main causes of disability in (TBI) is associated with a persistent loss of social au-
psychiatric disorders is associated with deficits in Execu- tonomy and inability to return to work [3]. The nature of
tive Functions, a very common cognitive abnormality these deficits, such as poor ability to criticize, distracti-
related to frontal or diffuse brain alterations typically bility, difficulty in abstract thinking, can compromise the
seen in these patients. The Executive Functions (EFs) are patients ability and motivation to adapt strategically to
intrinsic to the ability to respond in an adaptive manner his/her disabilities [4]. Psychiatric and neurological pa-
to new situations and they are also the basis for many tients with ED have independence and participation in

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28 P. D. GONALVES ET AL.

affected activities, especially in daily life activities [5], of anosognosia after stroke, memory functions, employ-
moreover, they are more likely to drop out from treat- ment, unemployment, autism, ecological test in schizo-
ment [6]. phrenia and children with attention deficit hyperactivity
However, pharmacological interventions do not com- disorder. We also decided to exclude 8 articles about
pletely remediate cognitive deficits and even second- techniques that stimulate not only EF but also other cog-
generation antipsychotics have a modest beneficial effect nitive and social functions (i.e., articles focusing on
on cognition in schizophrenia [7,8]. Therefore, non- theory of mind, social cognition, emotion recognition,
pharmacological intervention such as neuropsychological cognitive behavior therapy, aerobic exercises).
rehabilitation may be useful to improve EF. Moreover,
we believe the reduction of these deficits could signifi- 3. Results
cantly improve these patients emotional health, social
There were thirteen articles selected, which are briefly
functioning and independence skills, decreasing illness
presented below (Table 1).
burdens and other expenses [8]. Neuropsychological re-
For didactic purposes, the articles were classified in
habilitation (NR) focuses on empowering people affected
two groups, considering the EF theoretical model of Le-
by cognitive deficits, emotional and behavioral disorders
zak et al. [2]: rehabilitation of volition and planning, and
to achieve their maximum potential in psychological,
technics that improve purposive action and effective
social, recreational and vocational areas, as well as in
performance.
their daily functioning. The first step in order to plan an
A neuropsychological evaluation plays an important
appropriate intervention program is to map the neurop-
role to guide treatment for it is a way to investigate
sychological functioning, aiming to investigate the pa-
which cognitive abilities are intact and which ones have
tients cognitive strengths and weaknesses [9].
been impaired and how impaired they are [10].
It is relevant to review studies in this topic considering
the rare number of investigations that focus on NR of EF First Group: Rehabilitation of volition and planning in
in psychiatric patients. In the history of neuropsychology, patients with ECF impairments.
it is common to notice an adaptation of techniques used Volition is the capacity for intentional behavior (to
in neurological disorders to psychiatric patients. In addi- formulate a goal or to form an intention) that includes
tion, it is difficult to establish a clear overview about the motivation, self-awareness, social awareness, awareness
NR techniques and their effectiveness, due to the com- of ones physical status, of the environment and the situ-
plexity of the EF. The aim of this paper is to present an ational context. Planning refers to the identification and
update of techniques and NR models used in neurologi- organization of the steps and elements needed to carry
cal and psychiatric patients, in order to provide a theo- out an intention and achieve a goal [2]. The organization
retical background to discuss about the NR of psychiatric of directed behavior, which is related to frontal functions,
patients with ED. relies on the selection of sequential actions; not surpri-
singly frontal lesion patients often present goal neglect
2. Methods (disregard of a task requirement even though it has been
understood and remembered) [11]. Goals, a desired or
We performed a comprehensive literature review using expected future state [12], are essential in the rehabilita-
the following keywords: executive function, mental dis- tion process as they may enable the patient to return to
orders and rehabilitation in a database (PubMed), spe- the environment and to his/her normal life [9]. A goal
cific journals and books which were published until De- should be Specific, Measurable, Achievable, Realistic/
cember 2012. Our search methods resulted on 57 pub- relevant and Timed (SMART) [13]. As goal setting is the
lished articles plus articles from the references according core of the NR process, it is necessary to include the pa-
to the relevance of the key words. We only included ar- tients and all involved members (such as family and staff)
ticles about psychiatric disorders and/or TBI and NR. in it [12]. For example, in a TBI case report, the goals
After that, 36 articles were excluded because of their were: to explain consequences of brain injuries and their
topics were related to: prevalence, type and severity of impact on daily life, reduction of intrusive thoughts, to
cognitive deficits, gender differences in EF after TBI, use memory systems and planning for independent living
adaptation and/or validation of neuropsychological tests, activities, to use strategies for sustained attention in daily
neuropsychological profile and/or performance, biopsy- activities [9].
chosocial deconstruction of personality change fol- The Goal Management Training (GMT) [14] is com-
lowing acquired brain injury, changes in cognition posed of 5 stages: orientation, goal selection, definition
though aging, executive functions in the prediction of of sub-goals to achieve the main goal, memorize the
mortality in the elderly, peer-relationship difficulties in sub-goals and outcome. These structured exercises en-
children with brain injuries, kidney transplant recipients, courage the patients to monitor and evaluate their own
elderly patients with type 2 diabetes mellitus, mechanism performance in situations of everyday life. For example,

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 P. D. GONALVES ET AL. 29

Table 1. Articles about neuropsychological rehabilitation of Executive Function (EF).

Authors/year Sample Technique Duration Results
Ducan et al. /1996 [11] Frontal patients - - Goal neglect is related to frontal functions deficits.
Wade/1998 [12] Health care Goal Planning - Goal Planning was beneficial in the used setting.
Bovend Eerdt et al. /2009 Description about writing SMART
TBI SMART Goals/GAS -
[13] goals and using the GAS.
Levine et al. /2000 [14] TBI (n = 30) GAT 4 to 6 sessions Improvement daily life outcome measures.
Meningoencephalitis Less difficulty in a cooking task after the
Levine et al./2000 [14] GAT 13 sessions
(case report) intervention and in the 3-month follow up.
Brain damage
Von Cramon et al. /1991 [15] PST (n = 20) 25 sessions Improvements on problem solving tasks.
(n = 37)
Miotto et al./2010 Frontal lobes Improvement of the ability to manage novel
Attention & PSA 10 sessions
[17] lesions (n = 30) real life situation tasks.
Schizophrenia When performing multiple stimuli tasks
Harvey et al./2010 [20] Verbali-zing 1 test session
(n = 22) verbalization was effective.
12 hours
Kennedy et al./2008 [21] TBI MSI Positive immediate intervention results.
(average)
Simulation of Simulation of daily life tasks presented an
Couillet et al. /2010 [23] TBI (n = 12) 24 sessions
daily life tasks improvement on divided attention.
Experimental group presented an Improvement
Spikman et al./2010 20 - 24
Acquired Brain Injury Multi-faceted treatment on social participation and on Treatment
[24] sessions
Goal Attainment
Deep brain stimulation of Positive effect on addiction trough a
Alcohol dependent
Kuhn et al./2011 [32] the nucleus accumbens - normalization of the craving associated with
(n = 1)
Brain training anterior midcingulate cortex
Enhacing performance on conflict and
Rabipour et al./2012 Cognitively impaired Cognitive remediation
- inhibition tasks and decreasing reports
[19] individuals therapy
symptoms related to the disorder
Alcohol dependent Improvement in attention/executive
Rupp et al./2012
patients - - functions, memory, psychological well-being
[18]
(n = 41) and in the compulsion aspects of craving
Milioni All the valid strategies to be adopted after TBI
et al./2013 TBI - 12 sessions must include an integration of behavioral, familiar,
[10] educational and pharmacological approaches

Note: GAS = Goal Attainment Scaling. GAT = Goal Management Training. MT = memory training. MSI = Metacognitive Strategy Instruction. PST = prob-
lem-solving training. PSA = Problem Solving Approach. SMART refers to a goal that should be Specific, Measurable, Achievable, Realistic/relevant and Timed.
TBI = Traumatic Brain Injury.

the strategies that include a break in activities aimed at separate relevant from irrelevant information, draw con-
stopping and thinking, breaking goals into sub-goals by nections between the relevant items, generate possible
making them more manageable, using mental images and solutions and monitor their effectiveness [15-17]. The
to-do lists. The overall goal is to help individuals identify use of problem-solving training has proved very useful in
what works best for them, and promote the implementa- a study with TBI patients with ED: the patients submitted
tion of these strategies in everyday situations. Levine et to this training showed improvements in planning tasks
al. [14] compared GMT to motor skills training (MST); and in the therapists assessments of everyday behavior
their results showed that GMT was related to perfor- [15].
mance improvement on outcome measures similar to According to a study by Rupp et al. [18], cognitive
daily life activities. The GMT also had good results in a remediation through 12 individual computer-assisted
case of meningo-encephalitis with executive dysfunction, training sessions showed significant improvements on
which reported less difficulty in preparing meals, with alcohol-related impairments in purposive attention, func-
long-term gains. tion and memory, specifically alertness, divided attention,
The problem-solving training is another technique that working memory and delayed memory. Despite incre-
also uses teaching strategies and steps. This technique is mental benefit for some specific alcohol-related cogni-
the replacement of patients impulsive approach for ver- tive impairments, the results suggest that they are not for
bal systematic analyses of goals and means to achieve all aspect of cognitive functioning, such as inhibitory
them. Patients are encouraged to: identify the problem, control. There are some limitations in this study such as

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30 P. D. GONALVES ET AL.

the modest number of subjects (41 patients; 20 of them in ther effective cognitive strategy. This approach uses in-
the control group and the other 21 in the cognitive re- structions to teach people how to self-monitor through
mediation group) and the fact that control group patients identification of appropriate goals and performance pre-
were not exposed to a computer and the improvements diction in an activity in advance. The participants try to
may have been merely attributable to placebo effect. identify possible solutions based on: general predictions
Neurofeedback training is a computerized technique (which could be based on past experiences), self-monitor-
that trains individuals to actively control and change their ing or evaluation of performance during an activity, and
neural activation patterns by viewing the brainwaves they behavior change in choosing a strategy. For example: ask
emit after occurring. Rabipour et al. [19] in their study, the patient to predict his/her performance on the next trial,
advertise the improvement in mental functioning and ask him/her to analyzed previous performance [21,22].
increase of awareness. Nevertheless, it is still necessary A randomized trial with TBI patients has presented
to investigate the sustainability of these effects. improvement on psychometric measures and on everyday-
Miotto et al. [17] conducted a study with thirty patients life scales. This rehabilitation program of divided attention
presenting frontal lobe lesions using the attention and showed that experimental training (tasks close to patients
problem solving approach, which merges two techniques daily life: cooking, simulation of daily life situations,
already described (GMT and problem-solving training). summarizing news) when compared to control training
This approach is composed of three stages: problem (vigilance or simple visual search tasks and simple prob-
awareness, monitoring and evaluation, and developing, lem solving) had particular effect on divided attention,
initiating and implementing a plan. Their findings dem- which enabled patients to respond faster and more precise-
onstrated improvement in EF ecological measures, symp- ly when performing tasks with multiple stimulus [23].
toms evaluation and real-life activities. A prospective multicenter randomized control trial
Second Group: How to maintain a purposive action with acquired brain injury patients using the Multifaceted
and effective performance in patients with ECF impair- Treatment of Executive Dysfunction approach, which is
ments. based on Ylvisakers conceptual framework (self-aware-
Purposive action is the translation of an intention or ness, goal-setting, planning, self-initiation, self-monitor-
plan into productive, self-serving activity and involves ing, self-inhibition, exibility, and strategic behavior),
the ability to: initiate, maintain, switch, and stop se- showed treatment effects on outcome measures related to
quences of complex behavior in an orderly and inte- daily life executive functioning after intervention and
grated manner. Effective performance corresponds to the also lasting for 6 months after treatment [24].
ability of self-monitoring [2]. It was found that family can interfere with the success
The treatment will vary depending on individual defi- of the treatment. The collaboration in many areas such as
cits. The restorative approach is focused on reinforcing transportation, finances and emotional support can be
the functions that remains at least some extent intact. The associated to successful rehabilitation results [10]. Nev-
compensatory approach focuses on training the patients ertheless, emotional distress and family dysfunction may
on new strategies to cope with the impairment [10]. difficult or impede the recovery process because of the
Some patients present difficulties in accomplishing ac- patient vulnerability.
tions, despite of presenting preservation of planning However, there are several limitations in previous stu-
skills. One cognitive strategy used to improve this diffi- dies (see Table 1), such as several types of methodology
culty is verbalization, (speaking out loud, describing the (i.e. each study has a different number of sessions), few
steps of what one individual is doing while undertaking of instruments to measure EF rehabilitation effectiveness,
tasks). A study revealed that verbalization could improve lack of control group, lack of generalization of their
the performance on activities, which involves various EF findings in real life and absence of follow-up studies in-
elements in schizophrenic patients especially on multiple vestigating the maintenance of rehabilitation effects.
EF tasks [20]. These factors may not only significantly limit the com-
A review on 15 studies of interventions after TBI (fo- parability of data and results among studies, but also
cusing on the improvement of everyday problem solving, overestimate possible positive effects of NR (resulting in
planning, organization and multi-tasking) showed that false-positive effects of NR). Further research would
the most used techniques were: training multiple steps (in- help us to establish a greater degree of accuracy in Neu-
cluding metacognitive strategy instruction), training stra- ropsychological Rehabilitation.
tegic thinking, and training multitasking. In most studies, In sum, there is a need for the development of new
treatment was individual and the average treatment time tools to stimulate EF in neurological and psychiatric pa-
was about12 hours. All studies reported positive results tients. This represents an actual challenge for the rehabil-
after treatment (qualitative and quantitative analysis) [21]. itation of ED. Recently, we found that the use of board
Metacognitive strategy instruction (MSI) can be ano- games, especially chess, seems to be a promising tech-

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 P. D. GONALVES ET AL. 31

nique. As games require strategy development and prob- EF, but only future prospective studies could investigate
lem solving, they tend to facilitates cognitive and affec- the efficacy and the impact on patients daily routine of
tive self-regulation. Games can promote a great motiva- such interventions. At last, new studies should investi-
tion of the participants, due to their association with gate other factors and their influence on cognitive reha-
real-life issues and not with artificial or experimental bilitation.
materials [9]. Thus, the interaction with the other player
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