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Introduction
Cognitive processes include higher level executive functions such as attention, problem solving, and planning (Hayes, VanElzakker, Shin, 2012). Cognitive impairments occur when there is damage to the brain whether it be because of a direct injury to the head, or oxygen not reaching the brain such as through a stroke or a brain disease. Sometimes, “individuals appear to make a full physical recovery but can be left with subtle, “invisible” cognitive impairments that affect their ability to process information, organize tasks, and maintain a reasonable attention span,” (Purdy, 2012). Occupational therapists play a large role by providing cognitive remediation and/or compensatory interventions.

Theory
The Cognitive disabilities theory is based on recognizing that damage to the brain will affect an individual’s cognitive capacity ultimately resulting in dysfunction in performance. This theory supports that activities should meet the needs of the individual’s current cognitive level and compensatory strategies should be used to remove any barriers affecting performance in order to increase performance (Sames, 2015). This theory was selected because the head injuries our patient has sustained have caused cognitive deficits that may or may not improve.

Evidence
According to, Gagnon & DePrince, a lot of importance has been placed surrounding the topic of TBI’s especially in the veteran population, but there has not been a large focus on the effect of head injuries among women in or after leaving an abusive relationship (2017). Therefore, this study recruited 236 who had filed reports of “non-sexual assault intimate partner violence” to participate in a head injury screening. The HELPS Brain Injury Screening Tool was used to identify participants with a possible TBI. Out of the total participants, 80% reported having been hit on the head sometime in their lives and 56% screened positive for a mild TBI. This indicates that the population of survivors of domestic abuse are at a high risk of having cognitive deficits. Occupational therapists can utilize the Weekly Calendar Planning Activity (WCPA) created by Jean Toglia to assess executive functions or higher-level cognition of populations with possible cognitive deficits (2015).

Case Study
Throughout the course of an abusive relationship, Leslie sustained multiple head injuries.  As a journalist, she is expected to be able to schedule appointments, meetings, and attend to writing tasks in order to meet deadlines, but she is currently having difficulties completing her work tasks. Leslie expressed concerns with her distractibility at work.The therapist decided to administer the Weekly Calendar Planning Activity to identify cognitive deficits that may be impacting her work. The results indicated deficits in planning and attention which will be the focus of today’s session.

Intervention Plan

Problem Statement: Unable to follow weekly work routine secondary to impaired selective attention.
Outcomes: Desired outcomes include efficient and accurate planning for the work week.

Long term goals

1. Client will independently create a weekly work schedule and self-correct in order to plan work related tasks by discharge.
2. Client will attend to 30 minute work task with no more than one 30 second break in sustained attention by discharge.

Short term goals

1. Client will create a list of daily tasks with 3 verbal cues in order to improve planning in 1 week.
2. Client will identify 3 strategies for maintaining attention in the workplace by 2 weeks.
3. Client will habitually check work every 10-15 minutes to ensure accuracy in her writing assignments by 2 weeks.

Intervention format: Individual

Setting:

Individual 60 min session at the shelter for women and children who have been impacted by domestic abuse. Client would be seen at the shelter twice a week at 4:00 pm.

Supplies (if any)

• Paper
• Pens
• Weekly Calendar Planning Activity

Agenda & description

60 minute session

1.Leslie will identify daily work tasks. (10 min)

2. Leslie will prioritize work tasks (15 min)

3. Leslie will create a daily schedule (30 min)

4. Review/summarize the session and plan for following session (5 min)

Documentation

SOAP Note

S: “I can’t seem to focus when I’m at work. I get distracted by the smallest things.”

O: During today’s 60 minute session, client identified 6 daily work tasks with 2 verbal redirection cues. Client prioritized her chosen daily work tasks with 4 verbal redirection cues.The client then created a daily schedule to refer to with 6 verbal redirection cues. The client paused several times during the duration of each task and turned her head towards the direction of background conversations between other therapists and clients. She had to be redirected to the task multiple times. Also, client began to get agitated when she could not prioritize her daily activities in the correct order. Upon completing her daily schedule, the therapist noticed 3 errors. The therapist prompted the client to check her work but Leslie reported she did not see anything wrong. As she scanned her work she looked away from the paper 3 times. The therapist continued to provide prompts but ultimately had to point out the errors. Leslie corrected the errors.

A: During each activity Leslie required multiple verbal cues to redirect her attention back to the task at hand. She was distracted by other voices and people. This indicates that the external environment is affecting her ability to sustain attention on the task. Leslie’s difficulty prioritizing her work tasks indicates poor planning leading to frustration and distractibility. Leslie was unable to notice the errors in her work or sustain attention long enough to identify mistakes indicating her difficulties with self-correcting. Her ability to attend to tasks seems to be impaired by poor planning and the inability to self-correct. This is causing her to make errors in her work and take longer to complete tasks.

P: Client should continue OT treatment twice a week, focusing on planning, scheduling, and self-correcting mistakes. Client would further benefit from simulated work activities where she has an imposed time limit to complete tasks.

References

Gagnon, K. L., & DePrince, A. P. (2017). Head injury screening and intimate partner violence: A brief report. Journal of Trauma & Dissociation, 18(4), 635-10. doi:10.1080/15299732.2016.1252001

Hayes, J. P., VanElzakker, M. B., & Shin, L. M. (2012). Emotion and cognition interactions in PTSD: a review of neurocognitive and neuroimaging studies. Frontiers in integrative neuroscience, 6, 89.

Purdy, S. (2012). Returning to work with cognitive impairments. Retrieved from https://www.aota.org/About-Occupational-Therapy/Professionals/MH/Cognitive-Impairments.aspx

Sames, K. M. (2015). Impact of Models and Frames of Reference. Documenting occupational therapy practice (pp.50-55). Upper Saddle River, NJ : Pearson Education, [2015]

Toglia, J. (2015). Weekly Calendar Planning Activity Retrieved from https://myaota.aota.org/shop_aota/prodview.aspx?TYPE=D&PID=271083346&SKU=900369

Weekly calendar planning activity part I: Introduction and overview. (2017, Nov 29,). [Video/DVD] Retrieved from https://www.youtube.com/watch?time_continue=95&v=rJ4Czn17y0M