Rehabilitation of executive function: facilitation of effective goal management on complex tasks using periodic auditory alerts.

The 'dysexecutive syndrome' represents a major challenge to functional recovery and adaptation following brain injury--and an important target for rehabilitation. Previous reports of everyday difficulties, and performance on complex, life-like tasks, indicate that an adequately represented goal may become neglected as patients become overly engaged in current activity. Here we examine whether the provision of brief auditory stimuli, acting to interrupt current activity and to cue patients to consider their overall goal, would improve performance in a complex task. Ten brain injured patients completed a modification of Shallice and Burgess' Six Elements task under two conditions. In the 'Hotel' test, the patients were asked to try and do some of each of five sub-tasks within 15 min. As the total time to complete all of the tasks would exceed an hour, the measure emphasises patients' ability to monitor the time, switch between the tasks and keep track of their intentions. Without the external auditory cues, the patients performed significantly more poorly than age- and IQ-matched control volunteers, a common error being to continue performing one task to the detriment of beginning or allocating sufficient time to others. When exposed to the interrupting tones, however, their performance was both significantly improved and no longer significantly different from the control group on important variables. The results have value in assessment in helping to attribute poor performance to 'goal neglect' rather than, for example, poor memory or comprehension. They also suggest that providing environmental support to one aspect of executive function may facilitate monitoring and behavioural flexibility--and therefore the useful expression of other skills that may be relatively intact.